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Noyac

Noyac

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Not what you think. But I haven’t been present on this forum for a few months, so I thought I would post a case.

69yo morbidly obese ( BMI 48) female with severe COPD for a shoulder surgery, RCR.
A little more history reveals chronic paroxysmal A fib with PSVT/RVR yada yada yada
PFT’s show <10% improvement with bronchodilators and nothing that stands out.
Pulm med note states, pt requires 3LMP O2 continuous. Requires up to 6lpm with minimal activity. Crank the canister wide open if she even looks at a treadmill or flight of stairs. She will be evaluated for lung reduction surgery after shoulder surgery. Significant dead space and B upper lobe disfunction ( can’t remember the act terminology now but basically scarred tissue not functioning whatsoever in gas exchange). BMP ShowsCO2=28.

Plan: Extensive debridement and RCR In beachchair position in outpt setting connected to hospital.

Anrsthesia plan?
 
Good oral boards case.

First of all, she will need a detailed preop, including a proper H&P. Btw, what were her baseline O2 sats?

Regional is out given the severe COPD.

She needs a preop echo to possibly catch some serious RV dysfunction/PHTN. I will assume she has both, given the hypoxia. I will also assume the hypoxia is optimized (as in this is not some misdiagnosed CHF). That bicarb is unimpressive for a COPD-er, but it suggests chronic respiratory acidosis. Glad that the scarring is not at the base of the lungs.

She will need an ETT to control her ventilation (to avoid hypoxia/hypercarbia), plus to recruit whatever lung she has left, if needed. Good intraop pain control is also essential (pain also raises the PAP).

She will probably need a preinduction A-line, both because of size and because of PHTN/RV failure. She may need some inodilators/epi for the RV during the case.

IV access may be fun too, especially since she will need one for bolusing and one for pressors.

As rapid induction as her heart can tolerate (easy to say), because she will desat like a rock. Prop, sux, tube. Maintenance with sevoflurane, non-opiate analgesia as much as possible if extubation planned (see below), otherwise usual opiates. Have the surgeon inject local in the joint at the end, ideally exparel.

Definitely not an outpatient surgicenter case. Besides the possible difficult extubation due to her COPD, she will have serious pain control issues (unless exparel). It may be needed to leave her intubated for 2-3 days, less if arthroscopic, unless non-opiates (tylenol, toradol, lidocaine gtt, magnesium, ketamine gtt) are enough for her analgesia. Some opiates may be titrated, too, reversed with Narcan in the RR/sats drop too much.

Probably missed some stuff. Definitely the kind of case worth playing mental ping-pong about with colleagues.

Now tell us how you did it under regional. 😀
 
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I would still do this with a supraclavicular block instead of interscalene and LMA with spontaneous breathing and some pressure support.
Make sure you have made arrangements to transfer her to the hospital post-op if things don't go as planned.
 
I've been informed of the Superior Trunk Block (Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery | Anesthesiology | ASA Publications) that apparently has equivalent analgesia as interscalene without the hemidiaphragmatic paralysis. Haven't had a chance to see how it performs anecdotally.

A plan:
  • Would look for an echo but would not delay case to get a TTE
  • 2 good PIVs
  • Versed and then block
  • Superior trunk block + intercostobrachial block
  • Precedex... maybe a small dose ketamine gtt if I'm feeling cute
  • BIPAP (Pressure support on anesthesia machine with mask strapped on)
  • PRN fentanyl or ketamine for pain control if there's a failure in the block... which does happen
  • Pray the patient doesn't become disinhibited... which I've seen with just precedex during TAVRs.
  • If I'm concerned that I'm about to oversedate the patient or if the patient is getting disinhibited, convert to GA
  • If GA then LMA w/minimal pressure support. Yes there is risk of aspiration with BMI 48, but there's also a risk of bronchospasm, laryngospasm, need for deeper anesthetic, larger hemodynamic swings 2/2 the prior, etc with ETT. The less we do to the patient's airway, the better.
If I'm seeing the patient in pre-op and don't think they could tolerate much discomfort/awake surgery, I would block and go straight to LMAing/ETTing her.
 
Planktonmd said:
I would still do this with a supraclavicular block instead of interscalene and LMA with spontaneous breathing and some pressure support.
Make sure you have made arrangements to transfer her to the hospital post-op if things don't go as planned.
Click to expand...

I'm not a fan of LMA for beach chair, esp for morbidly obese COPD'er with potential heavy secretions / ventilation and oxygenation difficulties, and also b/c I don't have proseals. Ropi 0.75% LTA + ETT + PSV pro + intraop solumedrol/neb at the start will get you to much the same place.

FiO2@21 said:
I've been informed of the Superior Trunk Block (Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery | Anesthesiology | ASA Publications) that apparently has equivalent analgesia as interscalene without the hemidiaphragmatic paralysis. Haven't had a chance to see how it performs anecdotally.

A plan:
  • Would look for an echo but would not delay case to get a TTE
  • 2 good PIVs
  • Versed and then block
  • Superior trunk block + intercostobrachial block
  • Precedex... maybe a small dose ketamine gtt if I'm feeling cute
  • BIPAP (Pressure support on anesthesia machine with mask strapped on)
  • PRN fentanyl or ketamine for pain control if there's a failure in the block... which does happen
  • Pray the patient doesn't become disinhibited... which I've seen with just precedex during TAVRs.
  • If I'm concerned that I'm about to oversedate the patient or if the patient is getting disinhibited, convert to GA
  • If GA then LMA w/minimal pressure support. Yes there is risk of aspiration with BMI 48, but there's also a risk of bronchospasm, laryngospasm, need for deeper anesthetic, larger hemodynamic swings 2/2 the prior, etc with ETT. The less we do to the patient's airway, the better.
If I'm seeing the patient in pre-op and don't think they could tolerate much discomfort/awake surgery, I would block and go straight to LMAing/ETTing her.
Click to expand...

I give this lady about a 0% chance of tolerating awake + block. And also, just casually offering an urgent or emergent "convert to GA" for this kind of pt, who once they get started is going to be turned 45 degrees and strapped to the table like they're about to blast off in a Saturn V rocket, does not seem like the most sound of backup plans.
 
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Supraclav block 5cc + GETA
1Piv
A line would depend on competence of surgeon if tha case is going to be 2h or more i'd put one in.
 
vector2 said:
I give this lady about a 0% chance of tolerating awake + block. And also, just casually offering an urgent or emergent "convert to GA" for this kind of pt, who once they get started is going to be turned 45 degrees and strapped to the table like they're about to blast off in a Saturn V rocket, does not seem like the most sound of backup plans.
Click to expand...

Point taken. If I’m already wondering if she’d tolerate being awake I might as well skip to GA after block.
 
People really considering LMA for this patient?? BMI 48, $hitty lungs, and no real access to the airway if the $hit hits the fan. Ummm ....no. Low dose supeaclavicular block, ETT, low threshold to keep intubated. Inform the patient of the possibility of post op ICU care/MV. definitely not a surgicenter case.....
 
How was she diagnosed with copd if her pfts are unremarkable? Does she have fibrosis or emphysema (or both) in her apices?

This is pertinent because her significant oxygen deficit is not well explained by otherwise normal PFTs besides a poor ratio so this may indeed indicate significant right heart failure or phtn given her comorbidities.
 
you could also try a suprascapular nerve block here without knocking out phrenic. if you can find it 🙂
 
caveat87 said:
you could also try a suprascapular nerve block here without knocking out phrenic. if you can find it 🙂
Click to expand...
I was about to suggest this as well. Should be doable with US after finding the spine of that scapula. It’s a nice rescue/adjunct for pts experiencing posterior capsule pain s/p RCR
 
You’ll get lucky and do a few of these “outpatient”, and get by just fine. Just enough that surgeons will encourage (read: push) you to do more of them.

This lady needs to be done in the hospital, with the info that she may go to the ICU.

Surgeon can complain, but if you don’t tell them that some patients need to be taken seriously, nobody will..

MAYBE a supraclav, but still a chance that it works its’ way up to the phrenic. You’re in the hospital, now, so you’ve got the ICU if you need it. May be better to leave it alone.

LMA?? What is this, the UK?? You stick a tube in her, and spend the next 2 hours KNOWING you have a good airway...
 
The other thing I was considering late last night, when I wrote my post, was GA-LMA. I still don't know the echo results (and would love to know her DLCO, too), but I still assume she has PHTN/RV issues. The problem with an LMA would be the difficulty to control her hypercarbia, and possibly hypoxia if she derecruits (although the latter should be less likely in sitting position). Beyond the sheer access to the LMA in a shoulder surgery; usually not a good idea.

Another plan that would probably work would be what I said above, but with an unbolused interscalene catheter in place. I would bolus the catheter intraop, once the patient is intubated. If she cannot be extubated because of the diaphragmatic involvement, I would keep the catheter going for 1-2 days, then stop and extubate.

All of these also depend on the quality and speed of the surgeon, and whether the surgery can be done arthroscopically, for example, whether the surgeon can inject something like exparel at the end etc. If postop pain control is not a huge issue, this becomes almost a regular case (still not ASC level).

Also, those of you who like the idea of doing MAC in beachchair position, in a BMI 48 patient, should remember that these people desaturate like a rock, and that's even without coexisting respiratory disease. And that surgery, with "extensive debridement", should be painful, so that block had better both be perfect and not affect the phrenic nerve.
 
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DirtDocMD said:
You’ll get lucky and do a few of these “outpatient”, and get by just fine. Just enough that surgeons will encourage (read: push) you to do more of them.

This lady needs to be done in the hospital, with the info that she may go to the ICU.
Click to expand...
Agreed. How did this patient get cleared to have this procedure in a surgicenter?
 
Never in a million years would I put a LMA in this patient. Tube, local from surgeon, some adjuncts, light on the opioids.

I have to ask though - if they're contemplating lung reduction surgery for her, why on earth are we doing this rotator cuff now? Does she have a ceiling that has to be painted before Christmas? What's the rush? She's a 69 yo couch potato.
 
pgg said:
Never in a million years would I put a LMA in this patient. Tube, local from surgeon, some adjuncts, light on the opioids.

I have to ask though - if they're contemplating lung reduction surgery for her, why on earth are we doing this rotator cuff now? Does she have a ceiling that has to be painted before Christmas? What's the rush? She's a 69 yo couch potato.
Click to expand...
There is a fracture. I need to fix it!

 
Good questions FFP. I will now add some info to the case.
PFT RESULTS: obstructive pattern with insignificant Bronchodilator response, moderate reduction in DLCO corrected for alveolar volume.
Echo: normal LV, EF 60%, normal RV size and function., Dilated IVC, RVSP 40mmhg
normal valves, dilates coronary sinus

sugery center is connected to hospital. Does this change your plan as to where you do the case. we can get an a-line if needed at surgery center.

Those that say “no block” please explain your post op pain treatment and how this may effect her respiratory function. I know that academic thought is sometimes not to block these pts for fear of phrenic involvement. But you had better have a damn good plan if you don’t.
 
Noyac said:
Good questions FFP. I will now add some info to the case.
PFT RESULTS: obstructive pattern with insignificant Bronchodilator response, moderate reduction in DLCO corrected for alveolar volume.
Echo: normal LV, EF 60%, normal RV size and function., Dilated IVC, RVSP 40mmhg
normal valves, dilates coronary sinus

sugery center is connected to hospital. Does this change your plan as to where you do the case. we can get an a-line if needed at surgery center.

Those that say “no block” please explain your post op pain treatment and how this may effect her respiratory function. I know that academic thought is sometimes not to block these pts for fear of phrenic involvement. But you had better have a damn good plan if you don’t.
Click to expand...
You can probably get away with a low dose interscalene. Maybe 10 cc of 0.2 ropi. Hopefully will have less motor involvement. Tylenol, NSAID, ice pack. Would not discharge her with opioids but if she were staying in house ...
 
Surgeon: “Come on, do they really need to be done at the hospital?”

Response: “Well, do they really need a shoulder surgery?”
 
I see this type of patient routinely at my shop. Hell, they don’t even have half the work up that the OP’s patient did. Geta, possible a-line, and supraclavicular approach-you might see the suprascapular in the same view, inject there and hopefully you have less phrenic involvement. I would look at the interscalene groove too, if it’s the classic view and I can get a needle to it, I rarely get phrenic involvement since I can use a smaller volume and stay away from injecting anywhere close to the phrenic. Typically, in my experience, COPD patients do fine with a tube and have had no problems with extubating them afterward. Unless, they are a lung transplant candidate which this patient is not. Preferably, do this at the hospital, it’s a hassle to transport this patient from the surgery center to the hospital even if it’s connected.
 
Noyac said:
Good questions FFP. I will now add some info to the case.
PFT RESULTS: obstructive pattern with insignificant Bronchodilator response, moderate reduction in DLCO corrected for alveolar volume.
Echo: normal LV, EF 60%, normal RV size and function., Dilated IVC, RVSP 40mmhg
normal valves, dilates coronary sinus

sugery center is connected to hospital. Does this change your plan as to where you do the case. we can get an a-line if needed at surgery center.

Those that say “no block” please explain your post op pain treatment and how this may effect her respiratory function. I know that academic thought is sometimes not to block these pts for fear of phrenic involvement. But you had better have a damn good plan if you don’t.
Click to expand...
We have a surgery center connected to our hospital. This patient wouldn't qualify. She would have to be done in the OR where there is plenty of extra help around rather than a single anesthesiologist running 1:4 in a surgery center that's 1/4 mile of hallways away from the main hospital.

Having had bilateral shoulder arthroscopies with excellent pain control with interscalene blocks, but having phrenic involvement both times (80 hrs of pain relief with Exparel!) I'd be wary of a block.

Count me among the crowd that thinks this is not an appropriate procedure prior to her anticipated lung reduction surgery. If her lungs are that bad, shoulder procedures aren't high on the list of necessary procedures.
 
FFP said:
As rapid induction as her heart can tolerate (easy to say), because she will desat like a rock. Prop, sux, tube.
Click to expand...

Wouldn't you want a controlled induction instead of a rapid induction? Either way you're going to ventilate... and a rapid induction risks hemodynamic swings...
 
Suprascapular and infiltration is the safest if you can pull it off. ETT 100%.
Agree that the bigger picture is that this patient is being evaluated for lung reduction surgery and a RCR isn't at the top of the list of things that need to be fixed right now. Just because we can, doesn't mean we should. Have the lung reduction surgery eval happen first and see what that plan is going to be. If you have a high prevelence of Covid in your community hospital, this patient would have a high risk of mortality if they became symptomatic with Covid.

Just had an otherwise healthy 50 y/o Covid positive patient that presented to the OR with a perfed gastric ulcer that was attempted to be treated medically. Covid lungs. Clipping the trees as of a couple of days ago. Not sure if he's still around.
 
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MikeMerk-MtS said:
Wouldn't you want a controlled induction instead of a rapid induction? Either way you're going to ventilate... and a rapid induction risks hemodynamic swings...
Click to expand...

These are not mutually exclusive. A rapid induction can be 100% stable hemodynamically and it’s my preferred way to control the AW in most patients (using roc).
 
MikeMerk-MtS said:
Wouldn't you want a controlled induction instead of a rapid induction? Either way you're going to ventilate... and a rapid induction risks hemodynamic swings...
Click to expand...
Of course I would like it as slow and controlled as possible. But a BMI 48 with bad small lungs will desat fast and may be a pain to ventilate. Time is of essence.
 
sevoflurane said:
These are not mutually exclusive. A rapid induction can be 100% stable hemodynamically and it’s my preferred way to control the AW in most patients (using roc).
Click to expand...
Fair enough. But just to clarify, you're talking about modified RSI (as in prop, succ, ventilate for 30 seconds, tube...)?
 
MikeMerk-MtS said:
Fair enough. But just to clarify, you're talking about modified RSI (as in prop, succ, ventilate for 30 seconds, tube...)?
Click to expand...

So long as you are happy with your expired O2 b4 induction, you can skin this cat with mrsi or rsi in a very stable manner. No hemodynamic chances are expected especially if prepared with some purple.
 
sevoflurane said:
So long as you are happy with your expired O2 b4 induction, you can skin this cat with mrsi or rsi in a very stable manner. No hemodynamic chances are expected especially if prepared with some purple.
Click to expand...
Purple?

Also, just want to thank Noyac and those responding for keeping this thread on topic and interesting!
 
I hardly do thoracic cases but is she even a candidate for lung reduction surgery? I mean her echo is as expected and her PFT is remarkably benign. Speaking to the ortho guys at my place, the longer you wait to repair a rotator cuff, the higher chances of needing graft and longer recovery time and such. So, why wait? Will it change her anesthetic outcome if we wait 6 months for her lung reduction surgery and the recovery? I’m just trying to learn from smarter people on this board, not trying to be a smart***.
 
dannyboy1 said:
You can probably get away with a low dose interscalene. Maybe 10 cc of 0.2 ropi. Hopefully will have less motor involvement. Tylenol, NSAID, ice pack. Would not discharge her with opioids but if she were staying in house ...
Click to expand...
What if it doesn’t cover the pain? 0.2 ropiv isn’t very strong.
 
marr65 said:
I hardly do thoracic cases but is she even a candidate for lung reduction surgery? I mean her echo is as expected and her PFT is remarkably benign. Speaking to the ortho guys at my place, the longer you wait to repair a rotator cuff, the higher chances of needing graft and longer recovery time and such. So, why wait? Will it change her anesthetic outcome if we wait 6 months for her lung reduction surgery and the recovery? I’m just trying to learn from smarter people on this board, not trying to be a smart***.
Click to expand...
This patient is on home O2. Something not good is going on and I wouldn’t call that a benign PFT....
 
sevoflurane said:
Suprascapular and infiltration is the safest if you can pull it off. ETT 100%.
Agree that the bigger picture is that this patient is being evaluated for lung reduction surgery and a RCR isn't at the top of the list of things that need to be fixed right now. Just because we can, doesn't mean we should. Have the lung reduction surgery eval happen first and see what that plan is going to be. If you have a high prevelence of Covid in your community hospital, this patient would have a high risk of mortality if they became symptomatic with Covid.

Just had an otherwise healthy 50 y/o Covid positive patient that presented to the OR with a perfed gastric ulcer that was attempted to be treated medically. Covid lungs. Clipping the trees as of a couple of days ago. Not sure if he's still around.
Click to expand...
Now we are getting into the COVID part of all of this. Thanks SEVO.
We have open beds and ICU with a low COVID census. Therefore, we trying to do as many urgent cases as we can before the numbers start rising again. Maybe this is unwise maybe not.
This pt has dislocated her shoulder a couple times and she isn’t due to have her lung surgery for months at the earliest. Both pulm and cards weighed in on this case and said she is as good as she is going to get.
 
dannyboy1 said:
She will have to put her big girl pants on and deal.
Click to expand...
I’m not her to criticize anyone but I see my job as the one person ( that means anesthesiologist not me personally) that actually can get this pt through this safely and comfortably. I would prefer to take care of her pain as best as possible so as to avoid other issues like respiratory or other.
 
Noyac said:
Good questions FFP. I will now add some info to the case.
PFT RESULTS: obstructive pattern with insignificant Bronchodilator response, moderate reduction in DLCO corrected for alveolar volume.
Echo: normal LV, EF 60%, normal RV size and function., Dilated IVC, RVSP 40mmhg
normal valves, dilates coronary sinus

sugery center is connected to hospital. Does this change your plan as to where you do the case. we can get an a-line if needed at surgery center.

Those that say “no block” please explain your post op pain treatment and how this may effect her respiratory function. I know that academic thought is sometimes not to block these pts for fear of phrenic involvement. But you had better have a damn good plan if you don’t.
Click to expand...

The lady's lungs are bad enough and her PAP is bad enough (considering she has a dilated IVC, CS, and likely a degree of post-cap pulm HTN from afib, I'm guessing we're underestimating her RVSP using CW doppler of the TR jet...or she has bad RV diastolic dysfunction) that I wouldn't do this case if it were a free-standing ASC. However, if you are able to be "prepared for war" since you can steal supplies from the main OR and because if anything goes wrong you can just wheel her over to the main hospital then it's probably acceptable.
 
Noyac said:
This pt has dislocated her shoulder a couple times and she isn’t due to have her lung surgery for months at the earliest. Both pulm and cards weighed in on this case and said she is as good as she is going to get.
Click to expand...
Does not compute ... if they're considering lung reduction surgery they must think there's room for her function to get better ... 😉

This woman isn't an athlete. She's never going to do anything with that shoulder. I get it that future dislocations and subluxations are going to hurt and she wants the surgery to avoid that, but they won't hurt more than this surgery (block or no). I think this is a dumb surgery for her to have. She's also a corpse if someone coughs COVID-19 on her; there's a nontrivial chance she'll need to be admitted postop and pulmonary cripples in this pre-vaccine era should stay the hell out of hospitals. She should sit on her sofa with her O2 tank and quit doing whatever it is that dislocates her shoulder.

But that's between her and her surgeon. As vector mentioned, I'm also not buying that estimated RVSP, but I don't see her dying in the OR. I would do the case in an attached surgicenter like the one at my hospital, where the ICU and main OR are an elevator ride and hallway roll away. Other "attached surgicenters" not so much.

The orthopods I work with know where to find the suprascapular nerve and seem to get decent coverage by injecting local themselves, albeit with the shorter duration tradeoff. I wouldn't do a plexus block on her and risk phrenic involvement - I just don't see enough upside to it.
 
dchz said:
Pic?
Click to expand...

bc96b0d72823c0550aaba096bc7691_gallery.jpg
 
A) You block her, you intubate her, you hope phrenic involvement isnt significant enough that you can't extubate her...

B) You don't block her (and none of this suprascapular garbage), you intubate her, you give her opioids and deal with respiratory depression

In either scenario, she is going to have a high oxygen requirement post op limiting ability to go home

So who is worse to send home, this lady on opioids or this lady with a partial phrenic block?

I would argue its this lady on opioids who is worse off than the lady with the partial phrenic block...

Surgeon will give local, she will be OK initially in the PACU but after IV opioids and will be somnolent, at best you discharge her, her local will wear off and she will have peaking pain at home, peaking opioid use at home, high risk for something bad happening at home or needing to come back to ER

VS

You do the block, you are able to extubate, her pain is controlled, you KNOW the block is not going to get worse at home, you know its going to be peaking in the PACU, that phrenic nerve is not going to get weaker at home and unlikely to cause you a problem if its not already causing a problem in PACU...

So in the end I say do the block, hope to extubate, and if you can extubate and she looks good in PACU she will have a good chance of success at home..

And if you have to leave her intubated, I wouldnt feel bad because I would know that if she cant overcome a unliateral partial phrenic paralysis, she very mostly likely would not have been able to bounce back from the opioids required periop
 
pgg said:
Does not compute ... if they're considering lung reduction surgery they must think there's room for her function to get better ... 😉

This woman isn't an athlete. She's never going to do anything with that shoulder. I get it that future dislocations and subluxations are going to hurt and she wants the surgery to avoid that, but they won't hurt more than this surgery (block or no). I think this is a dumb surgery for her to have. She's also a corpse if someone coughs COVID-19 on her; there's a nontrivial chance she'll need to be admitted postop and pulmonary cripples in this pre-vaccine era should stay the hell out of hospitals. She should sit on her sofa with her O2 tank and quit doing whatever it is that dislocates her shoulder.

But that's between her and her surgeon. As vector mentioned, I'm also not buying that estimated RVSP, but I don't see her dying in the OR. I would do the case in an attached surgicenter like the one at my hospital, where the ICU and main OR are an elevator ride and hallway roll away. Other "attached surgicenters" not so much.

The orthopods I work with know where to find the suprascapular nerve and seem to get decent coverage by injecting local themselves, albeit with the shorter duration tradeoff. I wouldn't do a plexus block on her and risk phrenic involvement - I just don't see enough upside to it.
Click to expand...
P word!
 
What if you do a block and get the the phrenic and now she needs some support? What’s your plan?
Blade may have something to add here if he decides to participate.
 
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