ASC or Hospital?

[Versed0101]

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10 y.o. hispanic male about 80lbs. Dental Rehab extractions, fillings, etc...

T7 paraplegia
chronic lung disease (seems stable)
hypoventilation (vent only when sleeping) room air during the day
trach

Inspiratory wheeze on r side. Coarse breath sounds. No crackles. No cough.

Albuterol bid, flovent bid

My anesthesiologists group got hit by the Swine Flu so when they come back they are going to be swamped. Don't want to book it for the ASC if it's a hospital case.

Your thoughts?

 

[sweetalkr]

it probably depends on the comfort level of your doctors, but considering what I hear, and since the anesthesiologist hasn't seen it, better play it safe. I would say go with the Hospital b/c of autonomic hyperreflexia, etc..
but i am a 3rd year resident. ignore me

 

[periopdoc]

What is his insurance like?

- pod

 

[Fastrach]

Autonomic hyperreflexia in a dental rehab case?? That's a pretty enormous stretch, don't ya think?!

I'd hook up to the trach, dial up the Sevo, put on a little PEEP, take a fat dip of Cope, crank up the radio and let everyone at the ASC get on with life.

Oh wait, I'm guessing you dental types might frown on the Cope... 😉

 

[Planktonmd]

I think this case should be done in the parking lot as Jet would have said. 😀

 

[Versed0101]

it probably depends on the comfort level of your doctors, but considering what I hear, and since the anesthesiologist hasn't seen it, better play it safe. I would say go with the Hospital b/c of autonomic hyperreflexia, etc..
but i am a 3rd year resident. ignore me

Not a recent injury and we will be working above the level of damage. I thought it was pretty rare below T7. Thanks for the input. Patient is booked for the ASC.

 

[pgg]

Not a recent injury and we will be working above the level of damage. I thought it was pretty rare below T7. Thanks for the input. Patient is booked for the ASC.

I'd do it in the ASC.

The only thing I'd add is that autonomic hyperreflexia is a problem that typically manifests only after injuries are months old (usually cited as >6 months but I wouldn't bet on 5 being safe). The fact that it is "not a recent injury" does not itself reduce the risk; on the contrary, it implies he's in the window for badness. Otherwise you're right, it is rare below T7 and you are working above the lesion.

 

[huktonfonix]

I'd do it in the ASC.

The only thing I'd add is that autonomic hyperreflexia is a problem that typically manifests only after injuries are months old (usually cited as >6 months but I wouldn't bet on 5 being safe). The fact that it is "not a recent injury" does not itself reduce the risk; on the contrary, it implies he's in the window for badness. Otherwise you're right, it is rare below T7 and you are working above the lesion.

keep an eye out for possible post op urinary retention and bladder distention as well

 

[Jeff05]

what bladder distention? this guy definitely has a foley.
chronic injury - increased risk for AH. however, it is rare with lesions below T5. occurs secondary to stimulation below level of injury.

the main issue here is the "hypoventilation" whatever that means. does he have OSA? accessory muscle weakness (shouldn't be an issue with T7 lesion). he is VENTED overnight. i would say that here is an ASA 3 pediatric patient with a higher than usual risk of postop ventilatory depression.

i would strongly advise doing this case at the hospital, so if there are any problems the patient may be admitted overnight for monitoring.

 

[badgas]

what bladder distention? this guy definitely has a foley.
chronic injury - increased risk for AH. however, it is rare with lesions below T5. occurs secondary to stimulation below level of injury.

the main issue here is the "hypoventilation" whatever that means. does he have OSA? accessory muscle weakness (shouldn't be an issue with T7 lesion). he is VENTED overnight. i would say that here is an ASA 3 pediatric patient with a higher than usual risk of postop ventilatory depression.

i would strongly advise doing this case at the hospital, so if there are any problems the patient may be admitted overnight for monitoring.

I agree. Play it safe, schedule it at the hospital.

 

[jennyboo]

10 y.o. hispanic male about 80lbs. Dental Rehab extractions, fillings, etc...

T7 paraplegia
chronic lung disease (seems stable)
hypoventilation (vent only when sleeping) room air during the day
trach

Inspiratory wheeze on r side. Coarse breath sounds. No crackles. No cough.

Albuterol bid, flovent bid

My anesthesiologists group got hit by the Swine Flu so when they come back they are going to be swamped. Don't want to book it for the ASC if it's a hospital case.

Your thoughts?

1. I think this is an ASC appropriate case.

2. What's up with the right sided inspiratory wheeze and coarse breath sounds? Is this an acute process (foreign body aspiration, URI/pneumonia/bronchitis)? If acute, should the dental work be delayed until it's resolved? (If foreign body, he needs bronch first... If URI, maybe more debatable....)

3. Why should he have post-op respiratory depression if you use no long-acting benzos or narcs? Regarding muscle relaxants, no sux and you can possibly/probably get away without needing a non-depolarizing agent.

 

[bigtuna]

can't have OSA if trached

 

[huktonfonix]

what bladder distention? this guy definitely has a foley.
chronic injury - increased risk for AH. however, it is rare with lesions below T5. occurs secondary to stimulation below level of injury.

the main issue here is the "hypoventilation" whatever that means. does he have OSA? accessory muscle weakness (shouldn't be an issue with T7 lesion). he is VENTED overnight. i would say that here is an ASA 3 pediatric patient with a higher than usual risk of postop ventilatory depression.

i would strongly advise doing this case at the hospital, so if there are any problems the patient may be admitted overnight for monitoring.

how do you know? May self/parent cath.

 

[Jeff05]

can't have OSA if trached

also - what kind of "chronic lung dz"?

if patient has periods of apnea with trach - it's central sleep apnea. which is what i meant. there is something else going on if a t7 para requires vent support.

to jennyboo: this patient already has a baseline respiratory depression. his v/q mismatch will increase s/p a general anesthetic giving him less respiratory reserve with which to deal with his baseline respiratory insufficiency.

obviously anyone can slap on some sevo and let it ride for 99% of all of our cases and most of the time it won't matter. it's that one case in a career that gets you though. i think this kid should be done in a hospital setting. but, i don't know the real history and have not personally eyeballed the kid.

 

[Bertelman]

Versed, we all enjoy the clinical discussions, but presenting a half-assed history then asking for ASC v. hospital has become your m.o. Do you have a relationship with an anesthesia group to which you can pose these questions?

I hope you aren't using this forum to guide your clinical decisions.

 

[Versed0101]

Versed, we all enjoy the clinical discussions, but presenting a half-assed history then asking for ASC v. hospital has become your m.o. Do you have a relationship with an anesthesia group to which you can pose these questions?

I hope you aren't using this forum to guide your clinical decisions.

Thanks for all of the input! I am glad to have a resource of practitioners who genuinely care about the patient and who are willing to give their opinions on my cases.

 

[Noyac]

Asc