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Also,if you decide to block her what would you use as your agent? What block location? Some are touting supraclavicular, some the ISB and others the superior trunk block.
 
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Noyac said:
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?
Click to expand...

Hey @Noyac, good to see you posting. Good, challenging case. My thoughts are as follows:

1) she has about a 0% 5 year survival rate. She'll likely never have any sort of quality of life again.
2) She's better suited for a palliative care consult than ortho or thoracic surgery. BMI 48, O2 6LPM with minimal activity? Someone is considering lung reduction surgery? BWahahahhaha :laugh:
3) my thoughts these days are pulm and cards notes are irrelevant with regard to suitability for surgery/anesthesia. They're signing off on the fact that nothing needs to be done to her heart or lungs right now (though the pulm note is suspicious...).
4) if you're doing her at your ASC geez man, what patients are you taking care of in the big house? Since she can't get out of bed without a flood of oxygen to her face she goes directly to the big house where I am.
5) The plan for pain control is no different than it would be for anyone else. You either block, they have little to no pain, and you don't worry about whatever O2 exchange capacity you've knocked out because you've bargained they can handle it. Or you dont' block, they have pain and get a fair amount of opioids, and you don't worry about whatever O2 exchange capacity you've knocked out because you've bargained they can handle it.
6) In short, I push the surgeon not to do the surgery and have a frank discussion with the patient. I realize most COPDers do fine with GETA, but most of them aren't BMI 48 with O2 flood to face every time they have a bowel movement. I'm pushing for palliative involvement here.

If someone holds a gun to my head we do the following:

1) low volume supraclav (10cc)
2) intubate
3) aline if BP cuff isn't reliable
4) plan to extubate to CPAP or BiPAP but tell patient it's likely she goes to ICU intubated
5) even if she surprises us and flies through she stays overnight in case the block wears off and she requires opioid and more CPAP/BiPAP


Now, tell us you did it with block, nothing else, she was discharged 30 min post op, and climbed Mt Everest later that week. 🙂
 
SaltyDog said:
Posterior cord infraclav + suprascapular in the notch.
Click to expand...

I say if you can isolate the posterior cord without hitting the phrenic then you can probably block the whole plexus without hitting the phrenic, you can block suprascapular with US and infiltrate around the suprascacular artery
 
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Well I did the usual KISS method. Everyone in the group that reviewed the case weighed in and the suggestions were all across the board just as in this thread. None of them right or wrong just a personal preference. We discussed. Bipap over night, ICU bed on standby, Ketafol infusion, block vs no block, and monitoring.

I did a low ISB with 10cc0.5% ropiv with decadron and targeted the C7 root. I watched the spread and tried to keep it from spreading up and anterior to the C5&6 roots (trunks). Due to COVID staffing we have some pretty long turnover times and I was able to watch her for about 30 before surgery. She showed no respiratory compromise at this time. And total block to the digits.
In the OR she desaturated while moving over to the OR table (into the low 80’s). She was unable to lie flat so I sat her up 45 deg to see if she improved. She did and we continued. I then gently induced her with neosynhrone, propofol, and lidocaine. I gave her two or three breaths by mask which was easy and slipped in a #4 LMA. Then we positioned her for surgery. While prepping her shoulder she had that uncorrdinated belly breathing pattern. So I gave a little fentanyl to slow her down a bit and added a little pressure support. She was now easily pulling 500cc TV and maintaining ETCO2 of 35-37. I turned on some SEVO and that was about all I had to do for the case. She woke up supper easy on the table in the beachchair position and moved to the gurney. Off to PACU FOR ABOUT 10 min then phase 2 and home. I’ll admit I’m surprised she did so well. I also couldn’t get the BP cuff to work on her upper arm and had to move it to the forearm so I added neo infusion to keep her forearm cuff pressure at 120/70ish, her baseline was 100/60.

The pt was super excited and the surgeon was as well. He was not stocked to do the case by the way. But said if anesthesia will do it then I will Or something like that. Good surgeon and the case took a little over an hour. The shoulder was totally Crap inside and it was the right thing to do for her in hind sight. It would have been the wrong thing to do if we had hurt her. But the plan was to proceed cautiously and to have support if needed (ie: ICU ETC).
 
Noyac said:
Well I did the usual KISS method. Everyone in the group that reviewed the case weighed in and the suggestions were all across the board just as in this thread. None of them right or wrong just a personal preference. We discussed. Bipap over night, ICU bed on standby, Ketafol infusion, block vs no block, and monitoring.

I did a low ISB with 10cc0.5% ropiv with decadron and targeted the C7 root. I watched the spread and tried to keep it from spreading up and anterior to the C5&6 roots (trunks). Due to COVID staffing we have some pretty long turnover times and I was able to watch her for about 30 before surgery. She showed no respiratory compromise at this time. And total block to the digits.
In the OR she desaturated while moving over to the OR table (into the low 80’s). She was unable to lie flat so I sat her up 45 deg to see if she improved. She did and we continued. I then gently induced her with neosynhrone, propofol, and lidocaine. I gave her two or three breaths by mask which was easy and slipped in a #4 LMA. Then we positioned her for surgery. While prepping her shoulder she had that uncorrdinated belly breathing pattern. So I gave a little fentanyl to slow her down a bit and added a little pressure support. She was now easily pulling 500cc TV and maintaining ETCO2 of 35-37. I turned on some SEVO and that was about all I had to do for the case. She woke up supper easy on the table in the beachchair position and moved to the gurney. Off to PACU FOR ABOUT 10 min then phase 2 and home. I’ll admit I’m surprised she did so well. I also couldn’t get the BP cuff to work on her upper arm and had to move it to the forearm so I added neo infusion to keep her forearm cuff pressure at 120/70ish, her baseline was 100/60.

The pt was super excited and the surgeon was as well. He was not stocked to do the case by the way. But said if anesthesia will do it then I will Or something like that. Good surgeon and the case took a little over an hour. The shoulder was totally Crap inside and it was the right thing to do for her in hind sight. It would have been the wrong thing to do if we had hurt her. But the plan was to proceed cautiously and to have support if needed (ie: ICU ETC).
Click to expand...
Exactly how I would have done it!
 
With our healthy back log of elective RCR’s, I am not sure it would go at this point in time either to be honest.
 
Noyac said:
Well I did the usual KISS method. Everyone in the group that reviewed the case weighed in and the suggestions were all across the board just as in this thread. None of them right or wrong just a personal preference. We discussed. Bipap over night, ICU bed on standby, Ketafol infusion, block vs no block, and monitoring.

I did a low ISB with 10cc0.5% ropiv with decadron and targeted the C7 root. I watched the spread and tried to keep it from spreading up and anterior to the C5&6 roots (trunks). Due to COVID staffing we have some pretty long turnover times and I was able to watch her for about 30 before surgery. She showed no respiratory compromise at this time. And total block to the digits.
In the OR she desaturated while moving over to the OR table (into the low 80’s). She was unable to lie flat so I sat her up 45 deg to see if she improved. She did and we continued. I then gently induced her with neosynhrone, propofol, and lidocaine. I gave her two or three breaths by mask which was easy and slipped in a #4 LMA. Then we positioned her for surgery. While prepping her shoulder she had that uncorrdinated belly breathing pattern. So I gave a little fentanyl to slow her down a bit and added a little pressure support. She was now easily pulling 500cc TV and maintaining ETCO2 of 35-37. I turned on some SEVO and that was about all I had to do for the case. She woke up supper easy on the table in the beachchair position and moved to the gurney. Off to PACU FOR ABOUT 10 min then phase 2 and home. I’ll admit I’m surprised she did so well. I also couldn’t get the BP cuff to work on her upper arm and had to move it to the forearm so I added neo infusion to keep her forearm cuff pressure at 120/70ish, her baseline was 100/60.

The pt was super excited and the surgeon was as well. He was not stocked to do the case by the way. But said if anesthesia will do it then I will Or something like that. Good surgeon and the case took a little over an hour. The shoulder was totally Crap inside and it was the right thing to do for her in hind sight. It would have been the wrong thing to do if we had hurt her. But the plan was to proceed cautiously and to have support if needed (ie: ICU ETC).
Click to expand...


Nice job. I am not brave enough to do an LMA though.
 
Southpaw said:
Hey @Noyac, good to see you posting. Good, challenging case. My thoughts are as follows:

1) she has about a 0% 5 year survival rate. She'll likely never have any sort of quality of life again.
2) She's better suited for a palliative care consult than ortho or thoracic surgery. BMI 48, O2 6LPM with minimal activity? Someone is considering lung reduction surgery? BWahahahhaha :laugh:
3) my thoughts these days are pulm and cards notes are irrelevant with regard to suitability for surgery/anesthesia. They're signing off on the fact that nothing needs to be done to her heart or lungs right now (though the pulm note is suspicious...).
4) if you're doing her at your ASC geez man, what patients are you taking care of in the big house? Since she can't get out of bed without a flood of oxygen to her face she goes directly to the big house where I am.
5) The plan for pain control is no different than it would be for anyone else. You either block, they have little to no pain, and you don't worry about whatever O2 exchange capacity you've knocked out because you've bargained they can handle it. Or you dont' block, they have pain and get a fair amount of opioids, and you don't worry about whatever O2 exchange capacity you've knocked out because you've bargained they can handle it.
6) In short, I push the surgeon not to do the surgery and have a frank discussion with the patient. I realize most COPDers do fine with GETA, but most of them aren't BMI 48 with O2 flood to face every time they have a bowel movement. I'm pushing for palliative involvement here.

If someone holds a gun to my head we do the following:

1) low volume supraclav (10cc)
2) intubate
3) aline if BP cuff isn't reliable
4) plan to extubate to CPAP or BiPAP but tell patient it's likely she goes to ICU intubated
5) even if she surprises us and flies through she stays overnight in case the block wears off and she requires opioid and more CPAP/BiPAP


Now, tell us you did it with block, nothing else, she was discharged 30 min post op, and climbed Mt Everest later that week. 🙂
Click to expand...
How often do you ask surgeons to consult palliative rather than proceed with surgery? Haven’t done it before, so wondering how receptive surgeons are to that convo...
 
Noyac said:
Well I did the usual KISS method. Everyone in the group that reviewed the case weighed in and the suggestions were all across the board just as in this thread. None of them right or wrong just a personal preference. We discussed. Bipap over night, ICU bed on standby, Ketafol infusion, block vs no block, and monitoring.

I did a low ISB with 10cc0.5% ropiv with decadron and targeted the C7 root. I watched the spread and tried to keep it from spreading up and anterior to the C5&6 roots (trunks). Due to COVID staffing we have some pretty long turnover times and I was able to watch her for about 30 before surgery. She showed no respiratory compromise at this time. And total block to the digits.
In the OR she desaturated while moving over to the OR table (into the low 80’s). She was unable to lie flat so I sat her up 45 deg to see if she improved. She did and we continued. I then gently induced her with neosynhrone, propofol, and lidocaine. I gave her two or three breaths by mask which was easy and slipped in a #4 LMA. Then we positioned her for surgery. While prepping her shoulder she had that uncorrdinated belly breathing pattern. So I gave a little fentanyl to slow her down a bit and added a little pressure support. She was now easily pulling 500cc TV and maintaining ETCO2 of 35-37. I turned on some SEVO and that was about all I had to do for the case. She woke up supper easy on the table in the beachchair position and moved to the gurney. Off to PACU FOR ABOUT 10 min then phase 2 and home. I’ll admit I’m surprised she did so well. I also couldn’t get the BP cuff to work on her upper arm and had to move it to the forearm so I added neo infusion to keep her forearm cuff pressure at 120/70ish, her baseline was 100/60.

The pt was super excited and the surgeon was as well. He was not stocked to do the case by the way. But said if anesthesia will do it then I will Or something like that. Good surgeon and the case took a little over an hour. The shoulder was totally Crap inside and it was the right thing to do for her in hind sight. It would have been the wrong thing to do if we had hurt her. But the plan was to proceed cautiously and to have support if needed (ie: ICU ETC).
Click to expand...


I'm glad it worked out but wooo boy, this line made me nervous: " I gave her two or three breaths by mask which was easy and slipped in a #4 LMA. Then we positioned her for surgery. While prepping her shoulder she had that uncorrdinated belly breathing pattern. "

Now say the case got started and this belly breathing pattern didn't improve with narcotics, you increase the PSV and now PIP are getting close to 20 cmH2O, TV remains bad, LMA starts leaking, CO2 starts climbing up, PAPs go up, RV starts disliking it and her BP baseline is only 100/60....we are in a world of badness. I really don't like not having my backup plan of putting her on protected airway controlled mechanical ventilation + paralysis.
 
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I'm curious to know how the consent process went? Like did you advise her that she has a fairly good likelihood of death or that you may end up intubating with a prolonged ICU stay and possibly never getting the tube out? That's something that is kinda glossed over in residency and we don't much training on it, so I'd like to hear how you consent for something like this.
 
FFP said:
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. 😀
Click to expand...
:excuseme::excuseme::excuseme:
 
So did the group decide that block with potential for knocking out phrenic nerve is better vs no block and using opiates is better for obese COPDers? I was taught that COPD with home O2 use is kind of a contraindication to interscalene maybe even supraclav block, but like so many things from residency, may not be so black and white...
 
MirrorTodd said:
I'm curious to know how the consent process went? Like did you advise her that she has a fairly good likelihood of death or that you may end up intubating with a prolonged ICU stay and possibly never getting the tube out? That's something that is kinda glossed over in residency and we don't much training on it, so I'd like to hear how you consent for something like this.
Click to expand...

Lay it out on the line, preferably with the surgeon standing there with you.
 
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.
Click to expand...

^^^ best plan
Also, case done in large hospital, patient should have the expectation that she will stay overnight.

food for thought, patient looked great immediately postop, what happens tomorrow when the block wears off.
 
dchz said:
I say if you can isolate the posterior cord without hitting the phrenic then you can probably block the whole plexus without hitting the phrenic, you can block suprascapular with US and infiltrate around the suprascacular artery
Click to expand...

0% chance you bag the phrenic on an ICB. You could hit all 3 cords, but it won’t add anything for a shoulder. Hitting the suprascap in the notch with U/S is necessary with this approach unless you have a surgeon who is really good about getting it in the field. Used to work with a guy like that.
 
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vector2 said:
I'm glad it worked out but wooo boy, this line made me nervous: " I gave her two or three breaths by mask which was easy and slipped in a #4 LMA. Then we positioned her for surgery. While prepping her shoulder she had that uncorrdinated belly breathing pattern. "

Now say the case got started and this belly breathing pattern didn't improve with narcotics, you increase the PSV and now PIP are getting close to 20 cmH2O, TV remains bad, LMA starts leaking, CO2 starts climbing up, PAPs go up, RV starts disliking it and her BP baseline is only 100/60....we are in a world of badness. I really don't like not having my backup plan of putting her on protected airway controlled mechanical ventilation + paralysis.
Click to expand...
I agree but I have done thus for 15 yrs and never had to convert.
I made sure everything was good before westarted the case. You can always reprep.
 
MoMoGesiologist said:
So did the group decide that block with potential for knocking out phrenic nerve is better vs no block and using opiates is better for obese COPDers? I was taught that COPD with home O2 use is kind of a contraindication to interscalene maybe even supraclav block, but like so many things from residency, may not be so black and white...
Click to expand...
That’s the academic approach in my opinion.
 
Arch Guillotti said:
Nice job. I am not brave enough to do an LMA though.
Click to expand...
One person's brave is the next person's foolish.

That is only to say that I'm sure some here will say "Never in a million years should you put an LMA in this patient" while others will say "yeah, but maybe..."
 
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SaltyDog said:
0% chance you bag the phrenic on an ISB. You could hit all 3 cords, but it won’t add anything for a shoulder. Hitting the suprascap in the notch with U/S is necessary with this approach unless you have a surgeon who is really good about getting it in the field. Used to work with a guy like that.
Click to expand...
Could you elaborate. The board answer is there is a 100% chance of phrenology nerve block for interacalene.
 
Noyac said:
We should talk about that. Why I like them for this and why others don’t.
Click to expand...
Could you elaborate on this as well? I don’t understand what advantage an LMA gives you over an ETT, just more risk.
 
Sorry. Meant ICB. Oops. I’ll fix my post. Yes - near 100% chance of bagging phrenic on ISB.

:=|:-):
 
dipriMAN said:
Could you elaborate on this as well? I don’t understand what advantage an LMA gives you over an ETT, just more risk.
Click to expand...

The theoretical benefit is the lack of glottic/tracheal instrumentation, aka not poking the beast in someone with reactive airway disease. But as I said earlier you can avoid that by pretreatment with neb, methylpred, touch of opioid. Then achieve nice plane of hemodynamically stable anesthesia masking with volatile, D/L, Ropi LTA (+- lido jelly on cuff etc), then smooth sailing.

Effect of topical ropivacaine on the response to endotracheal tube during emergence from general anesthesia: a prospective randomized double-blind controlled study - PMC

The airway reflex such as cough is common accompanied with severe fluctuations of hemodynamics during emergence. This prospective double-blind randomized controlled trial tested the hypothesis that topical ropivacaine may reduce extubation response ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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I would have done the same (although 5cc is enough for ISB), LMA vs ETT would depend on patient morphology which you can only assess when you see the patient.

Btw @Noyac when did you start targetting roots with your neurostimulator?
 
vector2 said:
The theoretical benefit is the lack of glottic/tracheal instrumentation, aka not poking the beast in someone with reactive airway disease. But as I said earlier you can avoid that by pretreatment with neb, methylpred, touch of opioid. Then achieve nice plane of hemodynamically stable anesthesia masking with volatile, D/L, Ropi LTA (+- lido jelly on cuff etc), then smooth sailing.

Effect of topical ropivacaine on the response to endotracheal tube during emergence from general anesthesia: a prospective randomized double-blind controlled study - PMC

The airway reflex such as cough is common accompanied with severe fluctuations of hemodynamics during emergence. This prospective double-blind randomized controlled trial tested the hypothesis that topical ropivacaine may reduce extubation response ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...

I imagine there must be a trade off, gag reflex is probably blunted for a longer time with ropivicaine.

But you’re probably not aiming for a deep extubation in a BMI 50 patient anyway.


Sent from my iPhone using Tapatalk
 
Noyac said:
I agree but I have done thus for 15 yrs and never had to convert.
I made sure everything was good before westarted the case. You can always reprep.
Click to expand...

Same. I’ve done all my sitting shoulders with LMA for the past 15yrs. Never had a problem. They work even better in the sitting position than supine.
 
Since i have encountered quite a few of these cases my approach varies. DHB's low dose ISB of 5 mls does work successfully the vast majority of time. But, so does a selective anterior approach to the suprascapular nerve. Similarly, 10 mls of local around the superior trunk also provides good analgesia.
IMHO, the best pain control postop is an ISB but we balance good analgesia with risk each and every day.

I would have intubated this patient likely with a glidescope but if the LMA worked out then that is acceptable. I have SUPREMES available to me and would have used one on this large patient even in a standard supine case.


anesthesiology.pubs.asahq.org

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial

This study suggests that anterior suprascapular block provides noninferior analgesia compared to interscalene block, and better preserves vital capacity. While supraclavicular block was associated with some vital capacity preservation compared to interscalene block, the analgesia provided by...
anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org
 

Anesthesiology

anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org

Unique Phrenic Nerve-Sparing Regional Anesthetic Technique for Pain Management after Shoulder Surgery - PMC

Ipsilateral phrenic nerve blockade is a common adverse event after an interscalene brachial plexus block, which can result in respiratory deterioration in patients with preexisting pulmonary conditions. Diaphragm-sparing nerve block techniques are ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov


www.sciencedirect.com

Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block

Interscalene brachial plexus block (ISBPB) is an effective nerve block for shoulder surgery. However, a 100% incidence of phrenic nerve palsy limits t…
www.sciencedirect.com www.sciencedirect.com
 
One last comment is that 0.25% Bup combined with low volume is even MORE likely to reduce the incidence of clinically significant respiratory difficulty postop. The duration of analgesia is surprisingly only reduced by about 4 hours vs 0.5% Bupivacaine.
 
dipriMAN said:
Could you elaborate on this as well? I don’t understand what advantage an LMA gives you over an ETT, just more risk.
Click to expand...
There is an ENTIRE thread about that subject. Just search the forum.

There are a lot of advantages, main one being the ability to keep the patient lighter (an ETT in the trachea is WAY more stimulating).

Also, for a patient with RV issues or PHTN, avoiding PPV is golden. Again, much easier with LMA, because the patient is lighter, so more likely to breathe.
 
PeriPlexus:



Periplexus Injection.

Recently, the concept of ultrasound-guided periplexus (between the interscalene muscles and brachial plexus nerve sheath) injection of local anesthetic has been introduced for interscalene block. Palhais et al.17 recently reported that an ultrasound-guided extrafascial (periplexus) injection of 20 ml bupivacaine 0.5%, performed 4 mm lateral to the brachial plexus sheath not only provided similar analgesia compared with an intraplexus injection between the C5 and C6 roots but also reduced the incidence of diaphragmatic paresis from 90% to 21%. In addition, FEV1, forced vital capacity, and peak expiratory flow rates were less affected in the extrafascial group compared with an intraplexus injection, decreasing by 16 versus 28%, 17 versus 28%, and 8 versus 24%, respectively.17

Anesthesiology

anesthesiology.pubs.asahq.org anesthesiology.pubs.asahq.org
 
MoMoGesiologist said:
How often do you ask surgeons to consult palliative rather than proceed with surgery? Haven’t done it before, so wondering how receptive surgeons are to that convo...
Click to expand...

It depends on the surgeon. If you're a reasonable person and you've developed a good relationship with the surgeon then you mentioning 'palliative care' is likely to give them pause and start a productive conversation. In this particular case I have to believe the patient looked much better in person than on paper. Because honestly, 69yo's with a BMI 48 and that much of an O2 requirement with any sort of activity don't get RCRs in my experience.
 
MirrorTodd said:
I'm curious to know how the consent process went? Like did you advise her that she has a fairly good likelihood of death or that you may end up intubating with a prolonged ICU stay and possibly never getting the tube out? That's something that is kinda glossed over in residency and we don't much training on it, so I'd like to hear how you consent for something like this.
Click to expand...
NEVER lie to your patient. That's dereliction of duty. You have the choice of how you package it, but try to tell her the truth, the whole truth, and nothing but the truth, anytime there is a difficult decision to make. Why? Because you need to manage expectations (beyond the duty to your patient). The best policy is always to be honest. I will use malpractice lawsuits as a proxy for profound patient unhappiness, to illustrate my point.

Most lawsuits in medicine happen not just because of bad outcomes, but because of unrealistic expectations. If you set the wrong expectations, you set yourself up for failure. Some anesthesiologists think that the solution is lying to patients, usually by omission; in my experience, most patients without cognitive challenges will appreciate honesty, when coupled with competence. My typical spiel is something like: based on your medical history, these are the challenges that I see for your anesthesia, this is what can go wrong, and this is what I will do to try avoiding bad outcomes. As long as they agree to that plan, and you do exactly as you said, and your judgment was correct, nobody can fault you (and the patient usually doesn't). And if everything goes well, you will have a much more appreciative patient than one who has no clue of all the dangers you prevented/fixed.

Have you ever wondered why intensivists are sued much less than anesthesiologists? Because the expectations are different. Manage the expectations appropriately, both of your patient's and of your surgeon's, and neither will fault you for badness out of your control. But you need to educate them first.

If you think this post is an exaggeration, listen in to a surgeon obtaining consent just once. You will see that our usual consent process is a joke, and the patients see us accordingly, and give us the proportional importance.
 
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Arch Guillotti said:
Why?
Click to expand...


See post number 2 by FFP. I would be willing to try a Supreme LMA size 4 but once I saw the belly breathing the LMA would have likely been changed to an ETT.






264140
 
Advantages of the LMA Supreme
Picture LMA Supreme
LMA Supreme
The LMA Supreme is designed to make optimal insertion technique easier. Compared to the Unique LMA, the tube on the LMA Supreme is shorter and made of hard plastic. It is preformed into the optimal curve to allow even the inexperienced inserter to slide it into position over the glottic opening. The Supreme has a reinforced tip intended to prevent it from folding over and to allow it to easily slip under the arytenoids.
 
Good discussion.
Of note... even if you aim at C6-C7 or lower you can possibly get rostral spread.

This is a block I did today. 20cc’s during a single pass with the needle tip aimed @ C6. Spread is caudal, rostral, anterior and posterior. Doesn’t always spread this way, but it can if it’s a tight sheath with the right hydro dynamics.

1592080163113.jpeg
 
sevoflurane said:
Good discussion.
Of note... even if you aim at C6-C7 or lower you can possibly get rostral spread.

This is a block I did today. 20cc’s during a single pass with the needle tip aimed @ C6. Spread is caudal, rostral, anterior and posterior. Doesn’t always spread this way, but it can if it’s a tight sheath with the right hydro dynamics.

View attachment 309889
Click to expand...


If you place 5mls at this location then another 10-15 mls at the Supraclavicular level to block the suprascapular nerve (C5) postop analgesia is excellent and the phrenic nerve is mostly spared. I have done that about a dozen times on high risk patients with outstanding results (20 hours of postop analgesia on average).
 
Definitely done at a hospital with icu support , Supraclav catheter, awake aline, geta, gabapentin, ofirimev, avoid narcs, get her extubated slowly bolus catheter. Definitely not a asc case.
 
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