Ax-bifem case

[iron]

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I did this case about a month ago. I thought it was an interesting case to share.

71 year old male was sitting at the bar for several hours with some buddies. When he got up to leave, he found he couldn't walk. His legs were weak and numb. He was admitted to the hospital with poss. compartment syndrome. He had mildly elevated LFTs, platelets 95, increased CK o/w labs were normal. Over the next two days, feet were bluish, rheumatologists worked him up for myositis and finally vascular was called. He had extensive aorto-iliac occlusive disease. He is heavy smoker/drinker with little medical care received in past. An echo done this hospitalization showed EF 15%, PASP 53mm Hg, mod MR, dilated LV, LA, RA, decreased function of RV, diastolic dysfunction of LV. COPD changes seen on imaging. Over the days from ER to OR, LFTs in to the hundreds, Bili up, pt jaundiced, INR 1.2.

What to do, what to do?

Surgeon says he can do the dissection of the R. ax artery and femorals under local and only needs a few minutes of GA for the tunneling. Case is expected to last about 5 hours.

To summarize: COPD, pulm hypertension, mod mitral regurg, EF 15%, low platelets, increasing INR, increasing LFTs, jaundice...

 

[militarymd]

Most of his medical problems are not concerning to me except for the apparent alcoholic hepatitis.

He needs his "banana bag"...I assume he got that...and I would wait for his liver inflammation to subside...lft starting to trend down prior to going to the OR...unless of course, vascular stud says that his feet can't wait...

Than I'd put him to sleep and avoid hypotension...

 

[militarymd]

I also assume that when he got admitted, he got started on good nutrition??? He needs positive nitrogen balance ..and fast...although I would not use TPN...his gut is working, so good enteral nutrition with high protein content per nutrition consult.

thrombocytopenia in an alcoholic is multi-factorial....I wouldn't worry too much about it....

 

[Noyac]

I wouldn't be to excited about sedating someone for 5 hrs.

 

[stephend7799]

Most of his medical problems are not concerning to me except for the apparent alcoholic hepatitis.

He needs his "banana bag"...I assume he got that...and I would wait for his liver inflammation to subside...lft starting to trend down prior to going to the OR...unless of course, vascular stud says that his feet can't wait...

Than I'd put him to sleep and avoid hypotension...

I would also put and invasive arterial bp line, make sure he was type and cross matched,

 

[jetproppilot]

I did this case about a month ago. I thought it was an interesting case to share.

71 year old male was sitting at the bar for several hours with some buddies. When he got up to leave, he found he couldn't walk. His legs were weak and numb. He was admitted to the hospital with poss. compartment syndrome. He had mildly elevated LFTs, platelets 95, increased CK o/w labs were normal. Over the next two days, feet were bluish, rheumatologists worked him up for myositis and finally vascular was called. He had extensive aorto-iliac occlusive disease. He is heavy smoker/drinker with little medical care received in past. An echo done this hospitalization showed EF 15%, PASP 53mm Hg, mod MR, dilated LV, LA, RA, decreased function of RV, diastolic dysfunction of LV. COPD changes seen on imaging. Over the days from ER to OR, LFTs in to the hundreds, Bili up, pt jaundiced, INR 1.2.

What to do, what to do?

Surgeon says he can do the dissection of the R. ax artery and femorals under local and only needs a few minutes of GA for the tunneling. Case is expected to last about 5 hours.

To summarize: COPD, pulm hypertension, mod mitral regurg, EF 15%, low platelets, increasing INR, increasing LFTs, jaundice...

As J.P., (who Noy knows/worked with) once said in reply to how he would handle said-presented-complex case (during our residency),

"A little fentanyl, then etomidate, sux, tube, crank a little gas, GO WITH THE FLOW."



Hey Noy, J.P. actually said that in M&M!!!!

"......go with the flow..."

funny then. funny now.

But he was right.

Great words from a laid-back DVM-turned-MD.

 

[Noyac]

As J.P., (who Noy knows/worked with) once said in reply to how he would handle said-presented-complex case (during our residency),

"A little fentanyl, then etomidate, sux, tube, crank a little gas, GO WITH THE FLOW."



Hey Noy, J.P. actually said that in M&M!!!!

"......go with the flow..."

funny then. funny now.

But he was right.

Great words from a laid-back DVM-turned-MD.

I can totally see him saying that.

 

[bullard]

Iron, how did you end up handling this case? You left us hanging! 🙂

 

[iron]

Sorry, I havent been around in a while.

I was concerned on various fronts for this guy. My post presenting the case sounded pretty generic. But this guy was sick. I didn't think he'd survive a stay in the ICU - difficulty weaning the vent from pulmonary and cardiac stand points, worsening hepatic function, high risk for infections. So I wanted to maximize his potential for survival in the long term. Too often we think in terms of getting the patient through the OR and out of the PACU and neglect the post-operative course.

I used a propofol-ketamine infusion with a few doses of fentanyl. Put in a a-line - hooked up to an a-line waveform analyzer to get trends in cardiac output, left subclavian introducer for possible PA catheter (didn't need to, tho'). When it came time to tunnel, put the mask on with a bit of sevo. That lasted about 2 minutes or so. Otherwise, patient was breathing spontaneously on NC oxygen throughout case. Patient was awake, talking at end of case. Went to ICU overnight. And did amazingly well despite being dayglo jaundiced.

I admit the intraoperative management was a bit unorthodox but I felt that to give the guy a good chance of making it out of the hospital it needed to be.

 

[militarymd]

Sorry, I havent been around in a while.

I was concerned on various fronts for this guy. My post presenting the case sounded pretty generic. But this guy was sick. I didn't think he'd survive a stay in the ICU - difficulty weaning the vent from pulmonary and cardiac stand points, worsening hepatic function, high risk for infections. So I wanted to maximize his potential for survival in the long term. Too often we think in terms of getting the patient through the OR and out of the PACU and neglect the post-operative course.

I used a propofol-ketamine infusion with a few doses of fentanyl. Put in a a-line - hooked up to an a-line waveform analyzer to get trends in cardiac output, left subclavian introducer for possible PA catheter (didn't need to, tho'). When it came time to tunnel, put the mask on with a bit of sevo. That lasted about 2 minutes or so. Otherwise, patient was breathing spontaneously on NC oxygen throughout case. Patient was awake, talking at end of case. Went to ICU overnight. And did amazingly well despite being dayglo jaundiced.

I admit the intraoperative management was a bit unorthodox but I felt that to give the guy a good chance of making it out of the hospital it needed to be.

What made you think he would be difficult to wean? You did not state anything in the history to reflect impending resp failure or any history that would point to difficulty in weaning....

On top of that, the patient underwent an operative procedure that does not alter pulmonary mechanics....no reason for difficulty in weaning....unless the patient gets fluid overloaded in the OR.....and even then...difficulty in weaning would only occur in patients with severe CHF...ie sodium retaining state that is refractory to diuretic therapy.

 

[militarymd]

Sorry, I havent been around in a while.

I was concerned on various fronts for this guy. My post presenting the case sounded pretty generic. But this guy was sick. I didn't think he'd survive a stay in the ICU - difficulty weaning the vent from pulmonary and cardiac stand points, worsening hepatic function, high risk for infections. So I wanted to maximize his potential for survival in the long term. Too often we think in terms of getting the patient through the OR and out of the PACU and neglect the post-operative course.

I used a propofol-ketamine infusion with a few doses of fentanyl. Put in a a-line - hooked up to an a-line waveform analyzer to get trends in cardiac output, left subclavian introducer for possible PA catheter (didn't need to, tho'). When it came time to tunnel, put the mask on with a bit of sevo. That lasted about 2 minutes or so. Otherwise, patient was breathing spontaneously on NC oxygen throughout case. Patient was awake, talking at end of case. Went to ICU overnight. And did amazingly well despite being dayglo jaundiced.

I admit the intraoperative management was a bit unorthodox but I felt that to give the guy a good chance of making it out of the hospital it needed to be.

what's unorthodox about a MAC?