Another complicated case

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urge

urge

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urge said:
How would you anesthetize this patient.... for a lap Nissen fundoplication?


http://au.news.yahoo.com/thewest/a/-/world/9412531/chelsea-charms-shocks-british-tv-viewers/

What kind of problems do you anticipate? How will you deal with them?
Click to expand...

Holy crap.

Knee-jerk smart-aleck option: RSI general anesthesia for plastics to remove the blasted polypropylene implants and the fluid they absorbed. After she heals from reduction, THEN proceed with the Nissen. The implant device has been banned in the EU and US.

In seriousness, those things are a huge reservoir of fluid. A hefty fluid shift is concerning.

For induction; RSI. With 24kg extra on her chest, I don't think she would tolerate being apneic for more than a few seconds.

At 12kg per, there is a problem with maintaining tidal volume. The surgeons would be screaming for such high pressures to maintain pneumoperitoneum that I would think it would increase the risk of CO2 embolism, in addition to restricting ventilation even further. I am thinking 18 to 20cm H2O of pressure and up.

I never understood augmentation beyond a D cup. Personally, I think they are hideous, and more of a freak show than a sex status at that size. And the back pain has got to be excruciating.
 
Ronin2258 said:
Holy crap.

Knee-jerk smart-aleck option: RSI general anesthesia for plastics to remove the blasted polypropylene implants and the fluid they absorbed. After she heals from reduction, THEN proceed with the Nissen. The implant device has been banned in the EU and US.

In seriousness, those things are a huge reservoir of fluid. A hefty fluid shift is concerning.

For induction; RSI. With 24kg extra on her chest, I don't think she would tolerate being apneic for more than a few seconds.

At 12kg per, there is a problem with maintaining tidal volume. The surgeons would be screaming for such high pressures to maintain pneumoperitoneum that I would think it would increase the risk of CO2 embolism, in addition to restricting ventilation even further. I am thinking 18 to 20cm H2O of pressure and up.

I never understood augmentation beyond a D cup. Personally, I think they are hideous, and more of a freak show than a sex status at that size. And the back pain has got to be excruciating.
Click to expand...

I think they're big enough that you could maybe swing them off to the sides and support them on those OR carts (wheels locked) and divert most of the mass off the chest...
 
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urge said:
How would you anesthetize this patient.... for a lap Nissen fundoplication?

http://au.news.yahoo.com/thewest/a/-/world/9412531/chelsea-charms-shocks-british-tv-viewers/

What kind of problems do you anticipate? How will you deal with them?
Click to expand...

"Each breast reportedly weighs 12kg". I would post pics but I assume this violates SDN TOS.

I assume she will have difficulty with ventilation in the supine position.

Awake FOI in sitting position. Similar to an anterior mediastinal mass, I don't want to paralyze until I know ETT is in trachea. Even then, she may not tolerate GETA. If ventilation problems occur, would return to high reverse T position. Would use only short acting agents for this reason.

Would need to have discussion with surgeon regarding intraop positioning- would avoid T-berg as this would exacerbate pulmonary compression. Would also ask him to limit insufflation pressure for same reason.

Would have to tolerate increased peak pressures.
 
I would do a modified doggie style intubation with one handed support of each breast for the entire case.
 
Our burn OR has a rope and pulley system for suspending limbs for debridements - it could probably be rigged to relieve the pressure of her chest masses
 
KungPOWChicken said:
I would do a modified doggie style intubation with one handed support of each breast for the entire case.
Click to expand...

^---------- HILARIOUS

The Woman and her "Breasts"...

^------------HIDEOUS

Can someone tell me what procedure is outlawed now in the US and UK, wasn't following that. Clearly not implants, but implants over a certain size?

D712
 
doctor712 said:
^---------- HILARIOUS

The Woman and her "Breasts"...

^------------HIDEOUS

Can someone tell me what procedure is outlawed now in the US and UK, wasn't following that. Clearly not implants, but implants over a certain size?

D712
Click to expand...

Polypropylene string breast implants were banned. Other breast implants are still available.

http://en.wikipedia.org/wiki/Polypropylene_breast_implants

The implants themselves are hydroscopic due to the polypropylene, absorbing water and doing a gradual expansion of the breasts as they absorb water. It also irritates the implant pocket, causing the release of more fluid into the pocket. It is has no termination point, so the breasts (yes, hers included,) will continue to grow. The only way to stop it is to drain the excess fluid, or remove the implants.
 
doctor712 said:
^---------- HILARIOUS

The Woman and her "Breasts"...

^------------HIDEOUS

Can someone tell me what procedure is outlawed now in the US and UK, wasn't following that. Clearly not implants, but implants over a certain size?

D712
Click to expand...

I believe in the US, the limit for each breast is 850 cc (that would bring an A all the way to DD, if you need a size comparison). I remember reading in the news Sheyla Hershey went to Brazil to get 38KKKs since she surpassed the legal limit in the United States.
 
Ronin2258 said:
Polypropylene string breast implants were banned. Other breast implants are still available.

http://en.wikipedia.org/wiki/Polypropylene_breast_implants

The implants themselves are hydroscopic due to the polypropylene, absorbing water and doing a gradual expansion of the breasts as they absorb water. It also irritates the implant pocket, causing the release of more fluid into the pocket. It is has no termination point, so the breasts (yes, hers included,) will continue to grow. The only way to stop it is to drain the excess fluid, or remove the implants.
Click to expand...

I did not know this existed; Learn something every day. Interesting albiet disgusting.
 
I would think they would be great to slowly stretch the skin and tissue for a permanent implant after mastectomy, but not as a permanent implant.

Seriously, what is the point of these things, and what sort of distortion in body image does it take to get these?
 
PMPMD said:
"Each breast reportedly weighs 12kg". I would post pics but I assume this violates SDN TOS.

I assume she will have difficulty with ventilation in the supine position.

Awake FOI in sitting position. Similar to an anterior mediastinal mass, I don't want to paralyze until I know ETT is in trachea. Even then, she may not tolerate GETA. If ventilation problems occur, would return to high reverse T position. Would use only short acting agents for this reason.
Click to expand...

The images are easily googleable though:cool:.

I would just do an RSI. Awake FOI is just too much for me.
 
Another thing to consider about awake FOI. I suspect that a person who thinks this much augmentation as being ideal has some underlying psych issues that would make them intolerant of an awake procedure without one hell of a fight.

Trying to be gender neutral of this. I mean, if a guy thought his having prosthetic testicles the size of state fair-winning pumpkins were normal, I would suspect some underlying psych issues in him as well.
 
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