Appy + strep throat = ???

[ssmallz]

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Had an interesting case at work tonight and I'd love to hear other peoples thoughts on the matter.

20 y/o male pmh significant for excercise induced asthma. Uses albuterol daily for prophylaxis whenever he works out. Went to urgent care today b/c he had a really bad sore throat. Upon further review, he also had belly pain and was diagnosed w/an appy. Surgeon puts the case on and I go take a look at the pt

Records from urgent care are unavailable but I do notice a script for PCN. I call the urgent care, speak w/a PA who tells me that the pt has a pharyngitis but doesn't know whether the doc who saw him thought he had strep or a viral pharyngitis.

I take a look at the pt, temp of 102.7 down from 104 earlier today, wbc of 18. Ask him to open to wide and his tonsils are HUGE like JPP font huge. There's defiantly some white exudate on the tonsils and his voice sounds funny. When I asked him about his voice he said it was different then normal. Lungs sound clear and there is no stridor and I can visualize most of the uvula but it defiantly looks tight.

I thought about a spinal but quickly crossed that off the list b/c of the temp and white count. Had concerns about ventilating this pt after he went to sleep b/c of all the inflamation. Also had concerns about turning a throat infection into a PNA after intubation and post op edema in an already inflamed airway.

How would you anesthetize this pt? Would you delay the case to treat the sore throat? If you do intubate this pt do you extubate him at the end of the procedure or leave him intubated for a few days to let things settle down?

 

[Idiopathic]

sounds like a viral condition that resulted in both tonsillitis and appendicitis, not unreasonable since both have are associated with lymphoid hyperplasia. immune compromise and rare blood dyscrasia would be way down on my list

appy = not an emergency, especially if you think the airway is concerening. i could see hitting him with a dose of solumedrol and letting things cool down for a day. thats because im not a surgeon, but remember, 30% of appys are normal at path.

i have no problem doing a spinal in this patient, except for how comfortably he can rest/breathe laying supine, etc.

if you decide to go, i think that based on what youve said, he has significant supraglottic obstruction, and as such, is safest kept awake for intubation. may not be necessary, but its exactly the sort of case i reserve awake FOI for these days. (i.e. supraglottic obstruction where you may not be able to ventilate). if you decided to induce, i dont think an LMA would be an ideal backup, so i would have an aintree catheter and jet ventilation available. use a small tube (7.0)

based on how the intubation and case went, Id extubate at the end, unless something was dramatically intimidating along the way (had to force through the tonsils blindly, etc)

 

[jwk]

Geez I wish someone would tell our surgeons that an appy isn't an emergency!