Another challenging case

[GoldnLead]

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I was thrown add-on this case while transporting my last scheduled patient to PACU.

They expected it to follow ASAP. That's what happens when a clerk runs the board. (Don't ask).


65M alcoholic, poorly compliant patient. I'd actually performed a number of anesthetics on him in the prior months.

Severe AS (AVA 0.5cm2), HTN, PVD, smoker and I think he was homeless or living with his brother. May have had diffuse or non-significant CAD cause he was never considered for cardiac stenting.

Was initially scheduled for AVR but our CV surgeon (who has excellent judgment) cancelled cause he had toe gangrene (dry).

So I anesthetized him for a TAVI. Because of technical reasons, they couldn't deploy the graft (or proceduralist is pretty slick so it must have been a legit reason), so they did a valvuloplasty and called it a day.

A few weeks later, I'd anesthetized him in the cath lab for a combined femoral endarterectomy and popliteal stent. Case took about 5 hours. Lost about 1L blood but replaced it and he tolerated the procedure well.

We all know those procedures have a **** track record, and if there's anything good about death panels, hopefully they'll force us to just go straight to amputations.

So he had a toe amp. I guess he did well; I wasn't involved.

So he was readmitted a few days ago with SOB and worsening gangrene. Surgeon who fif the endarterectomy is away. Another got "volunteered" into seeing him and he's not too excited about it.

He now needs a BKA

So I do a chart review as the OR is setting up. Among other things, he came in a few days prior with a troponin leak and BNP of about 2900. Now it's 4300 or so. Go in to talk to the guy. Denies SOB, laying flat comfortably, but somnolent. No labored breathing based on my exam/observation. Brother is with him; he seems like a productive member of society. Both are eager to proceed (patient more so)....

Thoughts from the residents?? I'll post the outcome later on...

 

[IveGotTwins]

Any contraindications to regional/neuraxial?

 

[Ignatius J]

Any contraindications to regional/neuraxial?

Anticoagulation?

Can we get some vitals? Will look for SIRS criteria and rule in sepsis. Sounds like it needs to go sooner than later.

 

[Libertas]

do we have a recent echo after his valvuloplasty to clarify the valve area, gradient, new regurg from procedure, etc?

 

[GoldnLead]

Any contraindications to regional/neuraxial?

Anticoagulation?

Nothing. Maybe ASA but I have to admit, I didn't pursue this in the immediate term

Can we get some vitals? Will look for SIRS criteria and rule in sepsis. Sounds like it needs to go sooner than later.

VS WNL. No evidence of SIRS. This was dry gangrene.

do we have a recent echo after his valvuloplasty to clarify the valve area, gradient, new regurg from procedure, etc?

No recent echo.

 

[Libertas]

chest xray, tte, and some good vital signs on room air, careful exam of volume status. What have they been doing for his SOB since he was admitted a few days ago? Why is his volume status presumably worsening with rising BNP? Would definitely be worried about the valve

 

[BLADEMDA]

BNP levels below 100 pg/mL indicate no heart failure
BNP levels of 100-300 suggest heart failure is present
BNP levels above 300 pg/mL indicate mild heart failure
BNP levels above 600 pg/mL indicate moderate heart failure.
BNP levels above 900 pg/mL indicate severe heart failure.



I see your patients BNP was 2900 and is now over 4,000

 

[BLADEMDA]

I've performed BKAs under regional blocks. Your patient should tolerate a Femoral Popliteal block plus a touch of sedation with ketafol. Or, if he is not taking plavix, Coumadin, etc a lumbar plexus and sciatic block offers almost perfect operating conditions for a BKA.

 

[Orin]

I think the absolute BNP values are a bit confusing as the ranges for concern can be relatively lab specific. I've seen different BNP values/cutoffs from different hospitals.

The trend still suggests an acute exacerbation of CHF.

Depending on the urgency of the case and the patient's anticoagulation status, I would feel comfortable with dual femoral/subgluteal sciatic catheters for surgical anesthesia combined with light sedation of your choice, or any of Blade's suggestions.

If the BKA isn't urgent, this is technically an active cardiac condition with worsening of his CHF and would optimization/management prior to surgery. Perhaps at least ensuring rate control prior to incision?

If not, prop, sux, retrograde wire, tube?

 

[Ignatius J]

VS WNL. No evidence of SIRS. This was dry gangrene.



No recent echo.

Good case.

A CHF exacerbation contraindication to an elective procedure, so I guess it's important to determine how elective this is. Something to discuss with the surgeon. If surgeon says it is very crucial, "bad infection", "has to go", etc. I document it on the chart and go.

If he doesn't, I get an echocardiogram and wait for the CHF exacerbation to resolve before proceeding.

 

[Spinach Dip]

...retrograde wire...

Sound the alarms!

Someone said it!😱

 

[GoldnLead]

What have they been doing for his SOB since he was admitted a few days ago? Why is his volume status presumably worsening with rising BNP? Would definitely be worried about the valve

-Wasting taxpayer money.


Worsening CHF could have been due to his "troponin leak"--however else cardiologists sugar coat a NSTEMI in someone they don't want to cath--or failure of the valvuloplasty. I don't think he had afib.

Seems like patency rates for valvuloplasty aren't great:

http://www.ncbi.nlm.nih.gov/pubmed/2106852


I cancelled the case without following up since I had a bunch of other cases waiting. The vascular surgeon was more than happy to wait as well. I think they diuresed the guy a bit and his BNP dropped by about 1000 or so.


My partner ended up picking up the case the following day.

Did it with a fem+popliteal block. Went well. Good call as usual Blade.

 

[EdPierce]

epidural (or fem/sci nerve block combo). plus GA with inhalational induction and lma. this way he is totally asleep, no slugs of induction agents, plus all the advantages of regional.

 

[fakin' the funk]

epidural (or fem/sci nerve block combo). plus GA with inhalational induction and lma. this way he is totally asleep, no slugs of induction agents, plus all the advantages of regional.

Um, what?

This is a slam-dunk regional+MAC case. 30ml of 2% lidocaine with epi at each of the femoral and popliteal sites.

Is this more than the "toxic dose" of lidocaine? Yes.
Do I care? No. With U/S you can see if you're getting intravascular absorption immediately.
Blocks should be fully set-up within 20-25 minutes.
Since these are compressible sites, no issue with antiplatelet or anticoagulant drugs.
Leave a perineural catheter or two in if you really wanna be nice (and if you get paid for it).
Moderate sedation as Blade said.

 

[dhb]

This is a slam-dunk regional+MAC case. 30ml of 2% lidocaine with epi at each of the femoral and popliteal sites.

Is this more than the "toxic dose" of lidocaine? Yes.
Do I care? No. With U/S you can see if you're getting intravascular absorption immediately.
Blocks should be fully set-up within 20-25 minutes.

This doesn't make much sense either why would you use a toxic dose of lidocaine + epi in a vasculopath??
10cc of ropi or bupivacaine for the sciatic and for the saphenous and you're golden

 

[GoldnLead]

This doesn't make much sense either why would you use a toxic dose of lidocaine + epi in a vasculopath??
10cc of ropi or bupivacaine for the sciatic and for the saphenous and you're golden

Yep. No reason not to go for the longest duration of surgical anesthesia possible.

Also, no ropiv. Too $$$$. This is a Medicaid patient if we're lucky. Bupiv it is.

 

[Idiopathic]

Um, what?

This is a slam-dunk regional+MAC case. 30ml of 2% lidocaine with epi at each of the femoral and popliteal sites.

Is this more than the "toxic dose" of lidocaine? Yes.
Do I care? No. With U/S you can see if you're getting intravascular absorption immediately.
Blocks should be fully set-up within 20-25 minutes.
Since these are compressible sites, no issue with antiplatelet or anticoagulant drugs.
Leave a perineural catheter or two in if you really wanna be nice (and if you get paid for it).
Moderate sedation as Blade said.

pretty cavalier here, perhaps without fully understanding the "toxicity" of lidocaine. it does not result only from intravenous administration and many things affect plasma levels. you are considering giving someone 60cc of 2% 🙂eek🙂 or 1200mg or over 12mg/kg, likely? cardiac output is down, hepatic function is probably compromised, protein levels are low and theres probably some acidosis - all of which contribute to elevated plasma levels.

 

[Arch Guillotti]

^ Agree with above, that's a dumpload of lidocaine.

 

[Mman]

My first thought when I read this case was Femoral + Classic sciatic blocks with 20 mls of 0.5% Ropivicaine each (40 ml total). You'll have surgical anesthesia in about 15-20 minutes. Give him a little sedation and you will be fine. Depending on how far below the knee the BKA is, you just need the sciatic and saphenous nerves. Lat fem cutaneous and obturator only come into play up near the knee joint itself. No need to snow the patient and have their PCO2 climb up while you aren't paying attention.

 

[OB1🤙]

I think this is an easy case, and agree with the way it was managed.

Make it an AKA and it gets slightly trickier IMO.

 

[EdPierce]

Um, what?

This is a slam-dunk regional+MAC case. 30ml of 2% lidocaine with epi at each of the femoral and popliteal sites.

Is this more than the "toxic dose" of lidocaine? Yes.
Do I care? No. With U/S you can see if you're getting intravascular absorption immediately.
Blocks should be fully set-up within 20-25 minutes.
Since these are compressible sites, no issue with antiplatelet or anticoagulant drugs.
Leave a perineural catheter or two in if you really wanna be nice (and if you get paid for it).
Moderate sedation as Blade said.

Let me ask you for this "MAC" or sedation, how deep do you want him? will he be responding to your commands? if so, i wouldnt want to be that awake for a BKA. if not, why is all that IV narc better than sevo? im just saying - consider the patient perspective, being awake for a BKA is not ideal.

would you want to be awake for a BKA if you had to have one? Sure, if you have to do this awake/responding you have to. Compare the dangers of inhalational and LMA vs. "sedation" with no airway in a potentially very stimulating case. Im guessing you havent done the inhalational induction and LMA many times in adults. It works like a charm. Especially the cardiac players, nice and smooth. Again, its a BKA. its not a bunion or a cut down vascular procedure. you cant have a "patchy" block in either location (fem or sci) or you will risk developing chronic pain syndromes like RSD, phantom limb, PTSD, etc. You dont always do what is easiest, sometimes you go the extra mile for a well though out, quality anesthetic. Again, i do think sedation is reasonable, but think outside the box for a minute and consider all your options. Pop an LMA in the guy, procedure goes smooth with no movement, hes breathing great in the pacu due to limited narcs (not the tons necessary for "sedation"), blocks in place, its a sure shot. If you just do blocks you have to have a cool customer - or you are essentially doing a low depth TIVA with no airway. And to that I say - why not consider an LMA with inhalational induction/maintenance instead.

 

[BLADEMDA]

A LMA is fine. I'd use a BIS and avoid nitrous oxide. I would give minimal Sevo as needed for a BIS of 60. I'd still use ketafol for my induction agent.

Every had ketafol? This agent in a low dose infusion would be a great choice for a BKA combined with nerve blocks.

 

[BLADEMDA]

My first thought when I read this case was Femoral + Classic sciatic blocks with 20 mls of 0.5% Ropivicaine each (40 ml total). You'll have surgical anesthesia in about 15-20 minutes. Give him a little sedation and you will be fine. Depending on how far below the knee the BKA is, you just need the sciatic and saphenous nerves. Lat fem cutaneous and obturator only come into play up near the knee joint itself. No need to snow the patient and have their PCO2 climb up while you aren't paying attention.

I've done 6-7 BKAs over the past few months using an adductor canal block and a popliteal nerve block. All reported 0-1 pain scores in the pacu. But, I also used an LMA for the surgery itself.

I've performed BKAs with ketafol a dozen times utilizing femoral and popliteal blocks.

I've performed BKAs with a lumbar plexus and a sciatic block with nothing but a mg of midazolam.

I'm pretty certain that your post above is indeed correct.

 

[Mman]

Let me ask you for this "MAC" or sedation, how deep do you want him? will he be responding to your commands? if so, i wouldnt want to be that awake for a BKA. if not, why is all that IV narc better than sevo? im just saying - consider the patient perspective, being awake for a BKA is not ideal.

would you want to be awake for a BKA if you had to have one? Sure, if you have to do this awake/responding you have to. Compare the dangers of inhalational and LMA vs. "sedation" with no airway in a potentially very stimulating case. Im guessing you havent done the inhalational induction and LMA many times in adults. It works like a charm. Especially the cardiac players, nice and smooth. Again, its a BKA. its not a bunion or a cut down vascular procedure. you cant have a "patchy" block in either location (fem or sci) or you will risk developing chronic pain syndromes like RSD, phantom limb, PTSD, etc. You dont always do what is easiest, sometimes you go the extra mile for a well though out, quality anesthetic. Again, i do think sedation is reasonable, but think outside the box for a minute and consider all your options. Pop an LMA in the guy, procedure goes smooth with no movement, hes breathing great in the pacu due to limited narcs (not the tons necessary for "sedation"), blocks in place, its a sure shot. If you just do blocks you have to have a cool customer - or you are essentially doing a low depth TIVA with no airway. And to that I say - why not consider an LMA with inhalational induction/maintenance instead.

I think in a critically ill poorly compliant patient, his preference for not being awake during the case is a minor consideration. Now if I'm having a BKA, I'd like to be asleep but I'm also healthy. With a good surgeon a BKA is a 15-30 minute procedure max. And I don't think a block is going to be "patchy". It's not an epidural. Once you get the sciatic, you are 90% free and clear to an anesthetic with the exception of the saphenous and you can attack that however you want. If his sciatic block was inadequate, I'd grab the U/S probe and add an additional 10 mls of local in the pop fossa. If his saphenous block was inadequate, there are a variety of ways to rescue that block as well.

To me, the risk of GA in this patient far outweighs the risk of doing the case under a regional technique. I mean you can be as smooth as you want with an LMA, but it's still an LMA in a poorly compliant alcoholic with severe AS that may or may not be better after his valvuloplasty and CHF.

 

[Mman]

I've done 6-7 BKAs over the past few months using an adductor canal block and a popliteal nerve block. All reported 0-1 pain scores in the pacu. But, I also used an LMA for the surgery itself.

I've performed BKAs with ketafol a dozen times utilizing femoral and popliteal blocks.

I've performed BKAs with a lumbar plexus and a sciatic block with nothing but a mg of midazolam.

I'm pretty certain that your post above is indeed correct.

You are correct that there are a million ways to skin a cat on this one from a regional point of view. Get the sciatic and the saphenous and you are fine. Doesn't matter how you do it. Now if they start climbing up to the knee itself or AKA then those pesky LFC and obturator nerves come more into play.

 

[GoldnLead]

You are correct that there are a million ways to skin a cat on this one from a regional point of view. Get the sciatic and the saphenous and you are fine. Doesn't matter how you do it. Now if they start climbing up to the knee itself or AKA then those pesky LFC and obturator nerves come more into play.

Interesting point.


So let's say he needs an AKA in a few months and from a cardiac status, he hasn't improved.

What's the regional plan?

Also, he gets no say in whether or not he's awake during the procedure. 1-2mg midaz max. He's dug himself into this hole.

 

[Orin]

I'm dying to try a slowly dosed intrathecal catheter in this type of patient, assuming he's only taking aspirin.

For an inhalation induction for an LMA, it seems like they'd need to be pretty deep based on my experience with propofol and LMAs. Do you just crank the Sevo to 8% for a couple of breaths and then slip it in?

 

[VentdependenT]

This guy has a 1 yr survival rate with his valve. Fem sci.

 

[Idiopathic]

inhalation induction doesnt make any sense to me. i can give enough fentanyl/lidocaine/ketamine/propofol to either slip in an ett or place an LMA and wont have to overdose the patient on volatile to do it. start neo/nitro up front if you are worried about hypotension and his worsening CHF, keep the coronaries perfused and maintain sinus rhythm. preinduction art line, we can forego retrograde wire in this one.

 

[Mman]

Interesting point.


So let's say he needs an AKA in a few months and from a cardiac status, he hasn't improved.

What's the regional plan?

Also, he gets no say in whether or not he's awake during the procedure. 1-2mg midaz max. He's dug himself into this hole.

depends. For an AKA you gotta nail all 3 nerves from the lumbar plexus so you could do an LP block if their coagulation allows, but that carries some risk of epidural spread and the resulting hemodynamic shifts. Could try an epidural or IT catheter dosed slowly if coagulation allows. Femoral 3 in 1 block is a bunch of baloney if you need all 3 nerves blocked although you could theoretically block the obturator or LFC individually if you needed to after a femoral block. A sciatic block will still be necessary as well if you go for peripheral nerve block route.

At some point high enough up and depending on coagulation, you might be forced to do a GA. BKAs are nice, though, in that they are easier to do under regional than AKAs.

 

[EdPierce]

turn the sevo to 3-4%. Let him breath himself down to 0.7-0.9 MAC and give hime a couple minutes there (adults have larger FRC and take a little longer to go down with the mask) Then, while he is still breathing spontaneously, open his mouth and slip it in. Sometimes i give 10-20 of ppfl just prior to insertion. The vent never gets turned on, the case is essentially over as soon as it goes in. When the surgeons are done, take it out, next case. Its a very gentle induction if you have not tried it before.

 

[GoldnLead]

depends. For an AKA you gotta nail all 3 nerves from the lumbar plexus so you could do an LP block if their coagulation allows, but that carries some risk of epidural spread and the resulting hemodynamic shifts. Could try an epidural or IT catheter dosed slowly if coagulation allows. Femoral 3 in 1 block is a bunch of baloney if you need all 3 nerves blocked although you could theoretically block the obturator or LFC individually if you needed to after a femoral block. A sciatic block will still be necessary as well if you go for peripheral nerve block route.

At some point high enough up and depending on coagulation, you might be forced to do a GA. BKAs are nice, though, in that they are easier to do under regional than AKAs.

Yep, I've done one 3-in-1 block during residency and it was pretty much dismal. I know it's an n of 1 but my attending at the time didn't have such high hopes either. IIRC, we did it for practice in a county frequent flyer.

I'm thinking I'd do a lumbar plexus block, which we've had great success with for our TKAs when if/when the time comes.

 

[BLADEMDA]

Yep, I've done one 3-in-1 block during residency and it was pretty much dismal. I know it's an n of 1 but my attending at the time didn't have such high hopes either. IIRC, we did it for practice in a county frequent flyer.

I'm thinking I'd do a lumbar plexus block, which we've had great success with for our TKAs when if/when the time comes.

Slim,

I do 5-7 Lumbar plexus blocks every weeks for a variety of procedures EXCEPT Total Knee Arthroplasty. A lumbar plexus block is overkill for a Total Knee. A Simple Femoral or Adductor Canal block is all that one needs. I also add a selective tibial block.

Now, if you want to do the entire case under Regional block then a Lumbar plexus and high Sciatic (Labat, Franco, etc) are required for tourniquet pain.

As a frequent flyer of Lumbar Plexus blocks in all comers (obese, elderly, etc) this block is not without increased risks compared to U/S guided blocks. You need experience and skill to perform a Lumbar Plexus Block with the understanding of the dangers/pitfalls of this deep tissue block.

I treat Lumbar plexus blocks like Neuraxial blocks in terms of contraindications. If you won't do a spinal then you shouldn't do a lumbar plexus block.

FYI, low dose Isobaric spinals are wonderful for sick patients even those with tight Aortic stenosis. 7.5 mg of Isobaric Bupivacaine will preserve your BP quite nicely while giving you a great block.

 

[kazuma]

Slim,

FYI, low dose Isobaric spinals are wonderful for sick patients even those with tight Aortic stenosis. 7.5 mg of Isobaric Bupivacaine will preserve your BP quite nicely while giving you a great block.

I did an isobaric bupivicaine spinal on an 80 year old a few weeks ago and although n=1, I agree the BP was preserved quite nicely.

 

[Scotty_G]

Forgive me ignorance but why does isobaric bupivacaine not give you a sympathectomy? Is it because it doesnt travel much in the CSF? Also, I thought someone with bad valvular disease is not a candidate for spinal?

 

[Mman]

Forgive me ignorance but why does isobaric bupivacaine not give you a sympathectomy? Is it because it doesnt travel much in the CSF? Also, I thought someone with bad valvular disease is not a candidate for spinal?

Isobaric spinal sets up slower than hyperbaric and doesn't cover as many dermatomes so you get less sympathectomy, though you still do get some hemodynamic changes. Valvular disease is a relative but not absolute contraindication to spinal.

 

[BLADEMDA]

Isobaric spinal sets up slower than hyperbaric and doesn't cover as many dermatomes so you get less sympathectomy, though you still do get some hemodynamic changes. Valvular disease is a relative but not absolute contraindication to spinal.

Correct. Low dose Isobaric Bupivacaine will minimize hypotension especially with doses in the 5-7.5 mg range. Still, with severe Aortic Stenosis I am less likely to do any SAB and would prefer nerve blocks plus a little ketafol.

For an AKA a lumbar plexus block with a high sciatic block provides excellent surgical anesthesia. That would be my first choice for this patient undergoing an AKA provided there are no coagulation issues.