91 year old female, 88 lbs 4‘9, scheduled for umbilical hernia repair (1 cm or less), no known comorbidities. Patient is badly scoliotic. Her vitals and labs are all normal. What is you plan? (This is. A case I had today, pretty standard but it kinda went sideways midway trough).
-
CycleTrack and SDN are teaming up to make medical school admissions more transparent and accessible! Read the announcement to learn how we’re supporting the future of CycleTrack’s free application-tracking tools .
Another case
Started by Sleeplessbordernights
Get help with your application
Use all the free resources available to you from SDN: articles, guides, expert advising, forums discussions, and school research.
Lma
My attending said it was his last choice so we did not go that way
Given your limited presentation, LMA nearly always at the top of my list in this patient with this problem. That is a small hernia sac and should be about a 30 min case.
I have done a handful of umbilicals/inguinals in cripples with copious old school surgeon placed local and sh*tty MAC.
a lot of the approach is going to depend on how reasonable the surgeon and patient are.
there is nothing in your presentation that suggests difficult airway other than she is small, brittle, and old. If she isn’t kyphotic with a frozen neck and a reassuring airway exam then throw a tube in.
I’ve never spinaled an umbilical hernia, not that would never but plenty of other options for a small hernia so her scoliosis doesn’t mean much to me assuming she can lie flat and bend her neck.
Why was your attending so against a LMA? He must keyed in on something. so what am I missing? clearly you had some fireworks.
I have done a handful of umbilicals/inguinals in cripples with copious old school surgeon placed local and sh*tty MAC.
a lot of the approach is going to depend on how reasonable the surgeon and patient are.
there is nothing in your presentation that suggests difficult airway other than she is small, brittle, and old. If she isn’t kyphotic with a frozen neck and a reassuring airway exam then throw a tube in.
I’ve never spinaled an umbilical hernia, not that would never but plenty of other options for a small hernia so her scoliosis doesn’t mean much to me assuming she can lie flat and bend her neck.
Why was your attending so against a LMA? He must keyed in on something. so what am I missing? clearly you had some fireworks.
Tbh other than an small mouth the pt did not have any difficult airway signs.
This particular attending does not like LMAs and avoids them as much as she Can. So Yeah she decided to go for a spinal, 10 mg heavy bupi, 25 mcg fent
Went high?
Prop sux tube?
Prop sux tube?
Ugh. Why? Why annoyingly complicate this dumb case? And I love spinals but twisted old people and short cases are not great combos for spinals. This sounds like an academic center so I’m guessing longer case… I’d do spinal in a pulmonary cripple but you said no comorbidities so I’d guess she’s just old….
D
deleted162650
We all need some negative role models in residency.
Scoliosis causing significant cardiopulmonary effect? Restrictie lung disease? Pulminary hypertension? Is the patient even able to lay flat? Depending on surgeon and circumstances might consider local plus light sedation. Others already mentioned LMA. Spinal is pretty far down on my list of possibly plans for this pt. Just getting it in might be an exercise in frustration.
Undiagnosed severe AS?
But seriously (and obviously, this question doesn't work) why are you all even doing this case? Is it strangulated or incarcerated or something? Is it causing tons and tons of pain? Is this 91 y/o lady having trouble finding sexual partners cause they are turned off by the hernia?
This is the truth why waste time
Your attending sounds like a bozo op. Plenty of those in academia unfortunately.
Also, cases with this type of attending tend to go sideways often.
you did say about midway through. I’m guessing difficult spinal. You ended up thinking it was in. Started case and patchy/incomplete/failed necessitating a different plan
you did say about midway through. I’m guessing difficult spinal. You ended up thinking it was in. Started case and patchy/incomplete/failed necessitating a different plan
I think OP maybe in Mexico? But there are people who like to tempt fate everywhere everyday.
Had a 95 yo with gallstones, wanted a lap chole.
75 yo walking talking had a expansion of his aaa now 6.7cm, wanted operation…. I don’t know what are the right answers.
Exactly that, my attending did the spinal because I could not, but the pt had pain once surgery started, they used local, but We started having symptomsof LAST
Tbh the pt wasnt even aware of her sorroundings but surgery wanted to do it
They did a hernia repair on a demented 90 yr old? Who consented to it?
An alternative would be bilateral rectus sheath block then Propofol + Ketamine infusion... but why not just a good old LMA?
This. Thr spinal dose of local is a drop in yhr bucket
Whenever I have small patients, I ask surgeon what local they plan on using, and I tell them the maximum volume they can use. LAST is such a rare event with local infiltration, but I'd like to think that this adds another layer of safety.
This is so true; negative role models are as necessary as positive ones.
I had a similar case in training in a patient with severe AS. My attending insisted on a SAB. I realized just how hard it is to kill people that day as the patient did fine. Of course, there's the alternative too -- when you look at a patient the wrong way and they code.
Severe AS for spinal? That's some balls. What was the rationale for it?
Nothing that makes sense. In residency, I almost enjoyed the days with off the wall/borderline dangerous plans, or when SHTF… the full stomach IV infiltration during RSI type stuff… There was always this small sense of “well it’s someone else’s problem if something goes awry”. I wonder if that’s how CRNAs feel. I always felt like they were awesome learning opportunities… to experience crisis situations on someone else’s license. Now that I’m out on my own, it’s much different.
D
deleted87051
If the patient can’t lie flat, that’s a good reason to put them to sleep.
Low dose Isobaric bupi (7.5-10mg)for patients with mod-severe AS works out fine. Had a regional attending in residency who did it tons of times with no issues.
Just need to have someone who has balls to do it. It’s one of those dogmas, if the patient is harmed or dead, won’t be a lot of literature to support its use.
I still remember one of my attending wanted to do a spinal on one of the patients with mod-severe AS. My chief resident at the time basically threw the tray back at him and said, you do it, I am not going to have my name on the chart. I forgot what was the final anesthetics.
Good times good time.
I agree with sometimes things complicating things, but spinal usually simplifies matters. You have no idea how many GU cases that went smoothly because I chose a spinal vs.. a GENERAL..
YOu would have def. gotten LAST with that.
That is why they are so cavalier..
Really? who told you that? 🤔
I have been doing bilateral rectus sheath blocks almost daily for years and never had a problem
Last edited:
no you wouldn’t
Still sounds like a bad idea, and good luck defending it to your fellow anesthesiologists if something happened to patient. If you really wanted to do neuraxial for a patiwnt with severe AS, I would fluid load them, dose it up slow through an epidural. An art line wouldn't hurt.
Arch Guillotti
Senior Member
Staff member
Administrator
Volunteer Staff
Lifetime Donor
20+ Year Member
Mod AS never had a problem. “Severe” gives me pause. Depends on how bad it really is.
D
deleted87051
Aline, phenylephrine drip, and spinal would probably be okay in many cases.
D
deleted162650
Isobaric spinal is more hemodynamically gentle than inducing GA in many cases.
I put an isobaric 2.5cc in a patient yesterday for a hip revision. Lasted the whole 3.5 hour operative time, patient was 100/60 the entire case without any pressors. Patient was moving his legs 4.5 hours after the shot. It was glorious.
D
deleted162650
Not only that, but the BP comes down gradually and smoothly over several minutes with iso bupi. It’s very easy to stay on top of and correct if necessary.
I would venture that an isobaric spinal with a neo gtt is the most stable (and easiest to maintain stability) anesthetic you can do.
Out of curiosity, how do you define bad? By symptoms? Indexed Valve Area? Peak/Mean gradient? What about patients with low-output AS?
Arch Guillotti
Senior Member
Staff member
Administrator
Volunteer Staff
Lifetime Donor
20+ Year Member
Mostly guess😉
Why even bother with the spinal for GU cases. I've been doing 99% of mine just under prop/lido mac for a long time now.
Massive aspiration risk might be one indication. 2nd or 3rd trimester Pregnant patient might be another.
Arch Guillotti
Senior Member
Staff member
Administrator
Volunteer Staff
Lifetime Donor
20+ Year Member
obese, reflux, terrible lungs, long procedure, stimulating procedure, difficulty laying flat, etc etc etc
Hard to do a TURP under MAC, and the higher up recalcitrant stones in the kidney or UPJ really need more than a mac. Even an LMA wont do.. If they are just throwing a stent up, MAC all day long, but if they are lasering and basketing and doing all this high up...... it will be problematic
Also if they are bovieing lateral and you don't have an obturator block the legs may come in and you can perf the bladder
For long procedures or difficulty laying flat, wouldnt you want to tube them?
For bladder surgery, it is best to check with the urologist.
95yo - symptomatic cholelithiasis can suck daily, proceed with surgery if optimized
75yo - proceed with endovascular AAA repair
To quote the extremes and the borderline ridiculous, we've had people pulled out of hospice for total hips s/p fracture, and we've had people pulled out of stirrups after hours of being complete and pushing, to place a labor epidural. On those days, in my mind, Tina Turner's "Private Dancer" plays on...
Edit: My anesthetic plan would have been iGel if edentulous, otherwise any old LMA would do...
Last edited:
