Between a rock and a hard place...

[beezar]

Here's an interesting case:

Pt in his 60's, going for an urgent I&D groin wound which per surgery can no way be under local anesthesia.

Has a h/o aortic stenosis with last valve area (measured in 12/01) of 1.1cm2, and CHF. Medicine feels that the CHF has worsened recently and are worried about the pt's AS progressing towards the severe / critical range, and have ordered an echo for a few weeks later (nearly impossible to get on a weekend).

Also, he has active parotitis with a large mass and edema impinging on his larynx. cannot open his mouth more than 2 cm and jumps off the bed with the slightest touch on his neck because of pain. On top of that, the pt is minimally cooperative b/c he is somewhat demented and has bipolar disorder. The parotitis was because he became severely dehydrated (which he still was at that time) and formed a stone in his duct.

His INR from the same day by the was 1.4 which no one could explain.

And I haven't mentioned his other laundry list of problems including chronic renal insufficiency (creatinine at 2.9 or so), hypothyroidism, hypoparathyroidism, DM, others.

What would your approach be? This is a real case by the way.

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[militarymd]

I love cases like this...you are in a win, win situation....he's a sick guy, you get him through, you're a star...he dies...well, sick people die.

Sedation...haldol to make him still....fentanyl for pain...neuroleptic anesthesia

IV access....resuscitate him....endpoint would be a little full to too full...maybe even a little of pulmonary edema...let the ICU guys worry about his volume status later.

A-line to monitor....neo or levo in line to bp.

awake intubation.

 

[zippy2u]

How long will it take the surgeon, how involved is the I and D surgery and how much blood loss is expected. ---Zippy

 

[powermd]

Is an INR of 1.4 too high for a spinal? I would think that and some midazolam might be the easiest route to take, keeping some phenylephrine on hand to make sure he maintains his pressure. The parotitis and INR could be related. Somewhere in med school I learned there was a connection between liver disease and an enlarged/inflamed parotid.

If we were going to do a full GA, how does ketamine and a fiberoptic nasotracheal intubation sound?

 

[Justin4563]

sedate him with versed.. do one or two nerve blocks.. awake fiberoptic.. ( the only way to go on this one) soon as you see tracheal rings and confirm et co2.. go to sleep with amidate or ketamine.. remember in as you dont want to drop the afterload.. if its critical..(1.1 is not) you will get myocardial ischemia and kill the guy.. so have a stick of neosynephrine laying around

 

[jetproppilot]

Is an INR of 1.4 too high for a spinal? .

yes.

 

[zippy2u]

If the INR is 1.5 or higher spinal is out for me. With 1.4 ,homey will throw that spinal in in a New York heartbeat. ---Zippy

 

[militarymd]

If the INR is 1.5 or higher spinal is out for me. With 1.4 ,homey will throw that spinal in in a New York heartbeat. ---Zippy

We have a brave one here.

 

[jetproppilot]

Here's an interesting case:

Pt in his 60's, going for an urgent I&D groin wound which per surgery can no way be under local anesthesia.

Has a h/o aortic stenosis with last valve area (measured in 12/01) of 1.1cm2, and CHF. Medicine feels that the CHF has worsened recently and are worried about the pt's AS progressing towards the severe / critical range, and have ordered an echo for a few weeks later (nearly impossible to get on a weekend).

Also, he has active parotitis with a large mass and edema impinging on his larynx. cannot open his mouth more than 2 cm and jumps off the bed with the slightest touch on his neck because of pain. On top of that, the pt is minimally cooperative b/c he is somewhat demented and has bipolar disorder. The parotitis was because he became severely dehydrated (which he still was at that time) and formed a stone in his duct.

His INR from the same day by the was 1.4 which no one could explain.

And I haven't mentioned his other laundry list of problems including chronic renal insufficiency (creatinine at 2.9 or so), hypothyroidism, hypoparathyroidism, DM, others.

What would your approach be? This is a real case by the way.

Propofol 200mg, LMA #4, go with the flow.

WARNING: THIS IS A JOKE. DO NOT TRY THIS AT HOME. ALL INDIVIDUALS SEEN IN THIS POST ARE TRAINED PROFESSIONALS ON A CLOSED COURSE.