Blade's Cases

[MTGas2B]

THanks for the response. All excellent. Here is what I did for the guy.

I brought him to the O.R. ASAP. I would have liked more time for evaluation or just fluid replacement but IMPATIENT surgeons (he had his partner) led to my going right to the O.R.

The bowel was the likely source of sepsis (suspected perforated diverticulum). He was not distended so I skipped the NG tube pre-induction.
What do you think about that move? Next, I gave 100 ug Neosynephrine and placed the A-Line. Then, RSI with Etomidate and SUX. After induction Central line X 2 (cordis 8.5F and triple lumen) and LITERS of fluid.
He tolerated induction okay and only needed a little NEO. After 6 liters of LR I decided to address the HR of 140. I loaded with Digoxin (probably B.S.) and gave 20 mg Esmolol. He tolerated this well and HR slowed to 120 ( A.fib).
I gave 2 liters more LR and 500 Hextend. I slowly gave Lopressor in 1 mg increments up to 5 mg. The HR slowed to 105 (still A.fib).

The surgeons resected the bowel for the next 3 hours. I placed NG tube and the urine output was pretty good. After 3 hours the HR started to increase again to 140 and BP started to drop 78/48. I started NEO drip but changed to Norepi infusion. At this point total fliuds were 11 liters LR plus 500 ml Hextend. CVP=7 The case ended and I took the patient to the PACU.
The time now is 0100 and here are the vitals in Pacu on the Vent.

BP= 83/54
HR= 146
SAt= 99%
ABG= 7.31/31/135 BE= -8 on 50%
Hgb= 11.9 Platelets 180,000 INR=1.4 PTT-WNL

Urine output is still good 200 cc/hr and CVP=6.

Now what? The patient told me prior to induction NO HEART PROBLEMS and no history of A.Fib? The surgeon wants me to handle the situation and remember it is 0100.

Blade

He's beginning to get better, but according to your numbers he still need resuscitation, CVP low and a respectable base defeciet. 11 liters and some colloid. He looks like he has room for more fluid. Keep it going in the PACU/ICU where ever he's at now.

But his heart is still puzzling, and its gonna need some more work up. If the fluid doesn't slow him down I'd go back to the esmolol which looks like it worked. Hopefully you can slow him down, increase his filling time, and bring his pressure up. Has anyone checked cardiac enzymes yet or an ECG when is rate was down? Has his bout of sepsis kicked him into an MI or at the least some demand ischemia? Smoker, late 40s, stays at home when he's this sick my guess is isn't well followed as an outpatient.

New a-fib will probably need cardiology followup eventually. The big question my mind is, do you need it at one am. My guess is probably not. The only thing his a-fib needs right now is rate control. If your TEE savvy that's the easy answer. You can optimize his fluids a little better, and you can see if he knocked out some myocardium now that his ticker has been doing overtime. Even if you find some focal wall motion abnormalities, the night after his surgery is not the time to go to the cath lab, but it will put on the right path for managing his hemodynamics.

If you're not an echo man, then I think once you've given two or three more liters of fluid, and attempted rate control with esmolol again (maybe start a drip at this point), then its probably time for a PA cath. If your hospital has it you could try the LiDCO. Granted, he's septic, and that's the likely cause, but at this point you've achieved source control, and he should be getting a little better. Plus, new onset a-fib I didn't see a gas from his admit, or start of the case, what were his pH and BD? From resusitation alone you should some get improvement in his hemodynamics, his BP and HR and unchanged since the start of the case. You've done your duty for managing his hypotension, you started with pre-load (he's been well loaded), you moved on to afterload, the only thing left is contractility before you start messing with it too much you need more info on his heart.

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[jetproppilot]

He's beginning to get better, but according to your numbers he still need resuscitation, CVP low and a respectable base defeciet. 11 liters and some colloid. He looks like he has room for more fluid. Keep it going in the PACU/ICU where ever he's at now.

Concur. Surprising how much fluid these septic patients need.

New a-fib will probably need cardiology followup eventually. The big question my mind is, do you need it at one am. My guess is probably not. The only thing his a-fib needs right now is rate control.

Bingo again! Not surprised A fib occurred in this dude. .

Nice post there, bro.

 

[jeesapeesa]

Okay,

So here is my question regarding Case number 1. My hospital has XOPENEX readily available by Resp. therapy. It was my understanding (correct me if I am wrong here) that CLINICALLY Xopenex offered no real advantage over generic Albuterol. In case number 1 I could have ordered Xopenex treatment instead of using the patient's own MDI. Do you think that may have had any value to DECREASING his risk of intra-op or post-operative resp. symptoms?

Due to cost I have only ordered Xopenex twice in the past 24 months and both times were in the PACU (patient had active wheezing and patient had history of Xopenex working better). Theoretically, the S Enantiomer of Albuterol (Xopenex) should show superiority to the generic which has S and R components. Comments?

Blade

why not use advair diskus instead?

 

[BLADEMDA]

Good job so far on keeping him alive up to this point.

Now I would try to determine whether the unstable hemodynamics are because of a malignant rhythm or because of hypovolemia or because of sepsis or because of cardiomyopathy.

1. Feel his feet. If the feet are warm, it's because he's septic. And he needs vasopressor. Go with phenylephrine because norepi has some beta action and it'll continue to aggravate the arrythmia. Plus, phenylephrine will bring the HR down in and of itself and might even promote "eu-rhythmia."

2. If the feet are cold, it's either because he's hypovolemic, or in cardiogenic shock. What's the CVP? It looks to be 6-8? Start volume loading to a CVP of 12+. After that, if feet are still cold, drop in a TEE and look for another cause of shock: cardiogenic -- poor contractility from sepsis or acidemia? obstructive -- tamponade?

3. Once one and two are done, load with amio 150 x 2 and start amio infusion. Start antibiotics. Poor response to pressors? Start dexamethasone 4-10 mg q6h and send off cort-stim test. Optimize vent settings to protect lungs.

4. Relax. Good job. Now you just need a tincture of time. He'll either get better or get worse. There's nothing more you can do. If he gets better, congratulations. If he doesn't: you win some, you lose some.

Good responses. I have never had a problem as far as adrenal suppression with a single dose of Etomidate. I use it all the time for sick cases and will continue to do so.

In the PACU I gave him 4 liters more of LR. 500 ml more of Hextend. 2 mg of Lopressor and started Cardizem drip. The HR decreased to 128. CVP=8 Remember he is ON NOREPI from the O.R.

I thought about Amiodarone vs. Cardioversion (after TEE) but decided against it. Any thoughts about Amiodarone here? I chose Cardizem because a few years back SEVERAL good studies showed Cardizem worked well (slightly better than Esmolol) for rate control of A.fib. I have nver used the newer short acting B blocker 'Landiolol?' on a patient. Anyone have experience with it?

So, after the volume and the Cardizem HR=128 and BP=100/50 with urine output. Cardiology consult in the A.M. It is now 0200, do you want to do anything else or just maintain CVP? I skipped the TEE because I didn't see how my management was goint to change as I was not going to cardiovert at this time.

Comments?

Blade

 

[BLADEMDA]

I realize the role of steroids in adrenal suppression and sepsis but would most on this board give him Q 6 hour doses of steroids? Are most using steroids ROUTINELY for sepsis now? I am familiar with the studies of steroids in septic ICU patients but didn't think it was "routine" yet.

I didn't give him any steroids. Would you, Mil MD?

Blade

 

[militarymd]

I realize the role of steroids in adrenal suppression and sepsis but would most on this board give him Q 6 hour doses of steroids? Are most using steroids ROUTINELY for sepsis now? I am familiar with the studies of steroids in septic ICU patients but didn't think it was "routine" yet.

I didn't give him any steroids. Would you, Mil MD?

Blade

I believe the SCCM recommends its use ...in moderate doses (100mg hydrocortize q8H) in patients who have persistent vasoactive drug requirement DESPITE apparent adequate fluid resusitation.

The problem is defining adequate fluids.....the holy grail monitor doesn't exist...cvp is kind of crappy....

and single dose etimodate use is associated with increased long term mortality in severely injured patients......

 

[Planktonmd]

I believe the SCCM recommends its use ...in moderate doses (100mg hydrocortize q8H) in patients who have persistent vasoactive drug requirement DESPITE apparent adequate fluid resusitation.

The problem is defining adequate fluids.....the holy grail monitor doesn't exist...cvp is kind of crappy....

and single dose etimodate use is associated with increased long term mortality in severely injured patients......

This is a subject of a long standing debate and ongoing research.

 

[BLADEMDA]

I believe the SCCM recommends its use ...in moderate doses (100mg hydrocortize q8H) in patients who have persistent vasoactive drug requirement DESPITE apparent adequate fluid resusitation.

The problem is defining adequate fluids.....the holy grail monitor doesn't exist...cvp is kind of crappy....

and single dose etimodate use is associated with increased long term mortality in severely injured patients......

Okay,

So if I decide to wait 24 hours until giving the steroids and focus on optomizing fluid/volume in this patient that is acceptable? After all, he may respond nicely to this therapy.

I have been using SINGLE dose Etomidate for Induction of Critically ill patients for a long time-thousands of cases- with no apparent increase in mortality.

In your opinion, Etomidate is Contraindicated in septic patients from the E.R.?
What about low dose etomidate (10-12 mg or so) for trauma? I thought that MANY still use etomidate in these situations?

Blade

 

[Planktonmd]

I realize the role of steroids in adrenal suppression and sepsis but would most on this board give him Q 6 hour doses of steroids? Are most using steroids ROUTINELY for sepsis now? I am familiar with the studies of steroids in septic ICU patients but didn't think it was "routine" yet.

I didn't give him any steroids. Would you, Mil MD?

Blade

The steroids recommendations keep changing every few years, so I would use my clinical judgment, If the patient is not getting better just throw in some steroids and see what happens.
Cortisol levels and ACTH stimulation are most of the time meaningless, so if you feel that you need to diagnose Adrenal insufficiency just go ahead and treat empirically and see what happens.

 

[armygas]

This is a subject of a long standing debate and ongoing research.

This comes from the discussion section from Lipiner-Friedman et al. (2007) Adrenal function in sepsis: The retrospective Corticus cohort study

"In this study, some patients were included who did receive etomidate >24 hrs before the ACTH test. Treatment with etomidate was associated with an increased risk of dying, particularly in patients who did not receive steroids. This finding is in keeping with the observed increased mortality in multiple trauma patients sedated with etomidate. This observation underlines that even a short course of etomidate may have a sustained unfavorable impact on survival from critical illness and strongly suggests that it should not be used in patients with severe sepsis"

 

[BLADEMDA]

This comes from the discussion section from Lipiner-Friedman et al. (2007) Adrenal function in sepsis: The retrospective Corticus cohort study

"In this study, some patients were included who did receive etomidate >24 hrs before the ACTH test. Treatment with etomidate was associated with an increased risk of dying, particularly in patients who did not receive steroids. This finding is in keeping with the observed increased mortality in multiple trauma patients sedated with etomidate. This observation underlines that even a short course of etomidate may have a sustained unfavorable impact on survival from critical illness and strongly suggests that it should not be used in patients with severe sepsis"

This seems more like "opinion" than fact. Any studies showing a SINGLE dose of Etomidate is associated with increased mortality? Not retrospective junk but prospective, good data? I don't give a "course" of etomidate in my practice just a single dose.

Blade

 

[armygas]

This seems more like "opinion" than fact. Any studies showing a SINGLE dose of Etomidate is associated with increased mortality? Not retrospective junk but prospective, good data? I don't give a "course" of etomidate in my practice just a single dose.

Blade

Haven't gotten to read it yet but here is the abstract

Acute adrenal insufficiency after a single dose of etomidate.

Lundy JB, Slane ML, Frizzi JD.
General Surgery Service, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA 30905-5650, USA.
Acute adrenocortical insufficiency is a critical care emergency characterized by hemodynamic instability, lethargy, and cardiovascular collapse. Acute adrenal insufficiency has many etiologies, from rapid withdrawal of exogenous glucocorticoids to adrenocortical destruction to poor adrenal reserve after administration of steroid synthesis inhibitors. Etomidate, a parenteral hypnotic agent, is a steroid synthesis inhibitor. Although the use of continuous etomidate infusion in the intensive care unit fell from favor secondary to reports of adrenal crisis, single-dose etomidate for induction of anesthesia is common for the hemodynamically unstable patient or in patients who may not tolerate wide variance in heart rate or blood pressure. A case is presented of acute adrenocortical insufficiency and crisis after a standard induction dose of etomidate. Acute adrenal insufficiency should be suspected in intensive care unit patients who have undergone general anesthesia with etomidate induction and present with hypotension refractory to standard vasopressor administration.
PMID: 17456730 [PubMed - indexed for MEDLINE]

 

[The_Sensei]

Has BladeMDA ever admitted he was also EtherMD?

We all know it's true.......just wanted to hear it from the proverbial "horse's mouth".

 

[epidural man]

BladeMD.....then what?

I am getting impatient about this patient. This is better than a john grisham novel.

How come your surgeon wanted you to "take care or it?" I should have asked this from the beginning. Is that not strange to others? Is this is how things are in private practice? I mean, I think it is great that the surgeon recognizes you as the true perioperative specialist who is the most adept in this situation to take care of this critically ill patient, but it seems that in our hospital, surgeons are very reluctant to "ask for your help" and they seem to think that are very adequate at dealing with things like this.

 

[BLADEMDA]

BladeMD.....then what?

I am getting impatient about this patient. This is better than a john grisham novel.

How come your surgeon wanted you to "take care or it?" I should have asked this from the beginning. Is that not strange to others? Is this is how things are in private practice? I mean, I think it is great that the surgeon recognizes you as the true perioperative specialist who is the most adept in this situation to take care of this critically ill patient, but it seems that in our hospital, surgeons are very reluctant to "ask for your help" and they seem to think that are very adequate at dealing with things like this.

I have a history of taking care of ICU patients in my hospital. Thankfully, there are others who have taken over that task a few years ago. Still, the surgeons know they can rely on some of us for care of the tough cases in the PACU and ICU. Some surgeons want to be the primary ICU attending but most don't want to deal with all the phone calls and constant need for intervention.

Now, what about Etomidate? A few cases of "critically ill patients" needing steroid supplementation is no reason to avoid a great induction agent. All this means is give supplemental steroids a little more liberaly.

My bet is the vast majority of Board Certified Anesthesiologists are still using Etomidate in their practice. This would be a nice study for a Resident or ICU fellow. THe evidence for COMPLETE avoidance of etomidate as an induction agent is weak at best. Even weaker than the Trasylol data being bantered about these days.

Blade

 

[BLADEMDA]

The conclusion. The patient went to the ICU at 0300. I continued fluid therapy to maintain a CVP of 8. This seemed to result in a HR in the 120's, BP 100/50 and good urine output. THe NOREPI and CArdizem drips continued to the ICU.

In the ICU the patient got a 6 liters of LR from 0300-0800. The HR was now 115 and BP 123/62. The acidosis was improving and I had hope he was going to make it. The Cardiologist rounded at 0915 and thought I had done a pretty good job. He ordered an ECHO (TTE), told me Amiodarone would be started most likely tomorrow and that B-Blockers may be added to the treatment.

Over the next 48 hours the patient improved greatly. The Norepi was weaned OFF along with the cardizem. B-Blocker and Amiodarone were started and the patient converted to NSR on Post-op day three late in the afternoon. He was extubated on post-op day number 4 and walked out of the hospital on post-op day number 9.

As a side note no steroids were given in this case. The surgery, fluids and antibiotics did their job and the guy was fortunate to have a good outcome.

But, would you have done things differently for this guy? So far, we have opinions about Etomidate. What about Amiodarone in the PACU?

For those of you who avoid etomidate completely what is your induction agent of choice in this patient? Scopalamine and Fentanly? low dose Pentothal?

Blade

 

[epidural man]

But, would you have done things differently for this guy? So far, we have opinions about Etomidate. What about Amiodarone in the PACU?

For those of you who avoid etomidate completely what is your induction agent of choice in this patient? Scopalamine and Fentanly? low dose Pentothal?

Blade

Thank you for the conclusion.

I would have liked to see you give xigris, not because it would have done anything, but because it sounds cool and if you say it correctly, you sound funky!

Actually, I have read the articles on recombinant activated protein C, but have never seen it used. All the septic patients I have ever seen have never "fit the profile for its use" or whatever. I always wonder, "well who the hell is suppose to get this supposedly wonderful drug?"

Maybe you could have used fenoldopam for the same reason. Apparently this is a "wonderful" drug also, but again, no patient I have taken care of has had indications for its use.

 

[armygas]

For those of you who avoid etomidate completely what is your induction agent of choice in this patient? Scopalamine and Fentanly? low dose Pentothal?

Blade

Why not lower dose propofol? Its seems debated but an option.....

Propofol as an antiarrhythmic
N. J. Morgan-Hughes, R. M. Heames, H. Hack, S. Kannan , N. Sherwood

http://bja.oxfordjournals.org/cgi/content/full/89/5/798

 

[BLADEMDA]

Here are many peer reviewed articles on Etomidate and Critically ill patients.

Critical Care 2006;10 (4) R105
Critical Care 2007 April 35 (4) 1012-8
Critical Care 2007 May 24; 11 (3); R61

Another good study:

Chest 2005 March; 127 (3) 707-09

It seems if you use Etomidate (even a single low dose) MANY authors are recommending coverage with steroids.

Chest 2006; 10 (4): R105

This study recommends a moratorium on etomidate use period.
The two CHEST journal articles state that etomidate without steroid supplementation will cause 1in 5 patients that got the drug to DIE as a result. Pretty strong wording and a 20% mortality due to etomidate use!

The bottom line is pretty clear: Use etomidate at your own peril and if you use it at all YOU MUST GIVE STEROIDS for several days or more.

Blade

 

[urgewrx]

Thank you for the conclusion.

I would have liked to see you give xigris, not because it would have done anything, but because it sounds cool and if you say it correctly, you sound funky!

Actually, I have read the articles on recombinant activated protein C, but have never seen it used. All the septic patients I have ever seen have never "fit the profile for its use" or whatever. I always wonder, "well who the hell is suppose to get this supposedly wonderful drug?"

Maybe you could have used fenoldopam for the same reason. Apparently this is a "wonderful" drug also, but again, no patient I have taken care of has had indications for its use.

All the pts I have seen who got xigris, croaked.

What's up with fenoldopam?

 

[SexPanther]

All the pts I have seen who got xigris, croaked.

What's up with fenoldopam?

It is a selective DA-1 receptor agonist that acts as a vasodilator and also promotes naturiesis/diuresis, essentially it does the good things dopamine is purported to do at low dose (mediated by the DA-1 receptor) without all the other nastiness dopamine does at the alpha & beta adrenergic receptors.

The NEJM had a review article on it in 2001, seems like a nice IV therapy for severe HTN and it may play out to actually be nephroprotective (unlike dopamine which there is no evidence for a renal protective effect outside of the lab).

 

[CremeSickle]

Blade

Great references.

Ill be reading them today. I like etomidate in RSI in the trauma bay but i may reconsider it....

Here are many peer reviewed articles on Etomidate and Critically ill patients.

Critical Care 2006;10 (4) R105
Critical Care 2007 April 35 (4) 1012-8
Critical Care 2007 May 24; 11 (3); R61

Another good study:

Chest 2005 March; 127 (3) 707-09

It seems if you use Etomidate (even a single low dose) MANY authors are recommending coverage with steroids.

Chest 2006; 10 (4): R105

This study recommends a moratorium on etomidate use period.
The two CHEST journal articles state that etomidate without steroid supplementation will cause 1in 5 patients that got the drug to DIE as a result. Pretty strong wording and a 20% mortality due to etomidate use!

The bottom line is pretty clear: Use etomidate at your own peril and if you use it at all YOU MUST GIVE STEROIDS for several days or more.

Blade

 

[urgewrx]

It is a selective DA-1 receptor agonist that acts as a vasodilator and also promotes naturiesis/diuresis, essentially it does the good things dopamine is purported to do at low dose (mediated by the DA-1 receptor) without all the other nastiness dopamine does at the alpha & beta adrenergic receptors.

The NEJM had a review article on it in 2001, seems like a nice IV therapy for severe HTN and it may play out to actually be nephroprotective (unlike dopamine which there is no evidence for a renal protective effect outside of the lab).

Thanks

I thought it was something related to fenoldopam and sepsis.

It is my understanding that fenoldopam was a failure since it didn't live up to expectations.

 

[BLADEMDA]

How about another case for discussion.


20 year old African American female in Labor. No prenatal care and no OB Physician. She shows up in labor and is 36 weeks pregnant.

PMH

Obesity
Borderline HTN

PSH

None

Meds
None


Wt=152 Kg Ht=5'1" Vitals: 210/105 Pulse=112 RR=20

Labs:

Hgb= 12.7
Platelets:95,000
Chem-7- normal

The Resident called and asked you to see her about an Epidural. Want any other labs? Comments?

 

[epidural man]

How about another case for discussion.


20 year old African American female in Labor. No prenatal care and no OB Physician. She shows up in labor and is 36 weeks pregnant.

PMH

Obesity
Borderline HTN

PSH

None

Meds
None


Wt=152 Kg Ht=5'1" Vitals: 210/105 Pulse=112 RR=20

Labs:

Hgb= 12.7
Platelets:95,000
Chem-7- normal

The Resident called and asked you to see her about an Epidural. Want any other labs? Comments?

How uncomfortable is she currently? How is the baby doing? And how about a UA?

 

[dhb]

Low platlets and HTN: check dip stick for protein and liver tests if your concerned with eclammpsia/HELLP

any upper abdominal discomfort, headache?

 

[Planktonmd]

I would get PT & PTT
While waiting for the results(30 Min max), Start magnesium and treat her HTN, and then do the epidural.

 

[BLADEMDA]

I would get PT & PTT
While waiting for the results(30 Min max), Start magnesium and treat her HTN, and then do the epidural.

Positive protein in the urine. No headache. Normal PT and PTT. Normal LFT's. Repeat platelet count is 83,000. MGSO4 started by OB attending.

Would you do the Epidural in this patient with a platelet count of 95,000?
What about 80,000? BP treatment pending upon Epidural placement or not.

Blade

 

[BLADEMDA]

Remember her Weight and Height as noted in the case description. (334 lbs and 5'1")

Blade

 

[rmh149]

I would request a TEG. If it is normal, then I would do the epidural...after a 1500cc load (nothing less).

My cut off is a PLT of 50K before not attempting at all.

The weight doesnt bother me. I would just explain to the patient the expected difficulties and risks...but I would still expect to get it in.

Wait on treating BP till after the epidural obviously.

 

[BLADEMDA]

So, the extreme morbid obesity and falling platelet count on a pre-eclamptic patient doesn't concern you? The difficulty of epidural placement and epidural vein puncture is usually increased in this type of patient.

If TEG was unavailable would you do an Epidural in this patient? What about Catheter removal post delivery? What if the platelet count was down to 40,000 post delivery? Would you just pull the catheter as usual?

Again, if a platelet count is obtained prior to Epidural placement what is your cut-off (if any) ?

Blade

 

[Planktonmd]

Wait on treating BP till after the epidural obviously.

Why OBVIOUSLY?
What's so obvious in delaying treating Hypertension in a severely pre-eclamptic patient until you get your valuable TEG back and hopefully get an epidural in??

 

[rmh149]

So, the extreme morbid obesity and falling platelet count on a pre-eclamptic patient doesn't concern you? The difficulty of epidural placement and epidural vein puncture is usually increased in this type of patient.

If TEG was unavailable would you do an Epidural in this patient? What about Catheter removal post delivery? What if the platelet count was down to 40,000 post delivery? Would you just pull the catheter as usual?

Again, if a platelet count is obtained prior to Epidural placement what is your cut-off (if any) ?

Blade

Of course there is concern....but it wouldnt stop me from proceeding.

If TEG was unavailable, then I would not do the epidural. My cut off without the TEG is 100K.

How did the patient respond to the MAG load and gtt?

 

[Planktonmd]

So, the extreme morbid obesity and falling platelet count on a pre-eclamptic patient doesn't concern you? The difficulty of epidural placement and epidural vein puncture is usually increased in this type of patient.

If TEG was unavailable would you do an Epidural in this patient? What about Catheter removal post delivery? What if the platelet count was down to 40,000 post delivery? Would you just pull the catheter as usual?

Again, if a platelet count is obtained prior to Epidural placement what is your cut-off (if any) ?

Blade

I usually don't do labor epidurals if the platelet count is < 100,000, unless there is a strong indication like a high likelihood of complicated delivery with a difficult airway like the case presented.
In this case I may do the epidural as long the platelet count is above 50,000 and no other coagulopathy is present.
This is an epidural that might allow you to avoid a disaster later on and the benefit definitely outweighs the risk.

 

[epidural man]

Positive protein in the urine. No headache. Normal PT and PTT. Normal LFT's. Repeat platelet count is 83,000. MGSO4 started by OB attending.

Would you do the Epidural in this patient with a platelet count of 95,000?
What about 80,000? BP treatment pending upon Epidural placement or not.

Blade

i don't think the number of platelets matter so much as the trend of platelets. some one with a platelet count of 60 for the last 10 yrs is going to be fine. someone with a platelet count of 80 who came in with a plt count of 120 two hours previously is very concerning.

This lady concerns me for this reason.

 

[The_Sensei]

--------------------------------------------------------------------------------

Has BladeMDA ever admitted he was also EtherMD?

We all know it's true.......just wanted to hear it from the proverbial "horse's mouth".

 

[BLADEMDA]

i don't think the number of platelets matter so much as the trend of platelets. some one with a platelet count of 60 for the last 10 yrs is going to be fine. someone with a platelet count of 80 who came in with a plt count of 120 two hours previously is very concerning.

This lady concerns me for this reason.

I agree with you. After getting the second platelet number of 83,000 I called the OB attending. After discussion we agreed to proceed with a C-section in about 1 hour. We also agreed that I would get 30 minutes to do Regional/Spinal on her. If for some reason the First spinal was inadequate then a second attempt at Regional would be allowed.

The MGSO4 bolus and drip was not doing much for the BP. BP=195/103.
Thus, we agreed a C-Section was in order.

After bringing her to the O.R. I placed her in the sitting position. Finding midline was a challenge but I proceeded with the usual 25 gauage whitacre needle plus introducer. No luck. Despite thousands of spinals this lady was tough. So, I switched to a 22 gauge whitacre needle and on the next attempt clear CSF was obtained. I injected the 11 mg or so of Bupivicaine plus Dextrose and 0.25 mg of Duramorph. The pateint was placed supine with usual roll under her right side. A good level of T4 was obtained and the case proceeded with her belly being taped up.

Only about three doses of Phenyephrine 100ug were required during the case. Suprising considering her preoperative BP and the T4 level. She did get nauseated during the case right after the spinal block was placed.
Baby Female delived 9/10 apgars and the case went well.

I have found that the extremely obese rarely get a headache with a 22 gauge whitacre needle. If they do get a headache it is usually quite mild and resolves in a few days. This lady did not get a headache at all and stayed 96 hours in the hospital.

I don't use cutting needles in OB patients at all. Do you guys? My preference is for a 25 gauge whitacre whenever possible but will use a 22 gauge whitacre with the really big women. At my institution we deliver about 3,000 babies per year. The C-section rate is around 25-30% (large no pay/medicaid population) so we are familiar with post dural puncture headaches. Over the past ten years we have done ONE blood patch when a 25 gauge whitacre needle was used for a mild headache (the woman wanted the patch). This statement can not be made in the old days when 25 gauge Q needles were used regularly. There were many patches for headaches on these patients.

Blade

 

[rmh149]

I agree with you. After getting the second platelet number of 83,000 I called the OB attending. After discussion we agreed to proceed with a C-section in about 1 hour. We also agreed that I would get 30 minutes to do Regional/Spinal on her. If for some reason the First spinal was inadequate then a second attempt at Regional would be allowed.

The MGSO4 bolus and drip was not doing much for the BP. BP=195/103.
Thus, we agreed a C-Section was in order.

After bringing her to the O.R. I placed her in the sitting position. Finding midline was a challenge but I proceeded with the usual 25 gauage whitacre needle plus introducer. No luck. Despite thousands of spinals this lady was tough. So, I switched to a 22 gauge whitacre needle and on the next attempt clear CSF was obtained. I injected the 11 mg or so of Bupivicaine plus Dextrose and 0.25 mg of Duramorph. The pateint was placed supine with usual roll under her right side. A good level of T4 was obtained and the case proceeded with her belly being taped up.

Only about three doses of Phenyephrine 100ug were required during the case. Suprising considering her preoperative BP and the T4 level. She did get nauseated during the case right after the spinal block was placed.
Baby Female delived 9/10 apgars and the case went well.

I have found that the extremely obese rarely get a headache with a 22 gauge whitacre needle. If they do get a headache it is usually quite mild and resolves in a few days. This lady did not get a headache at all and stayed 96 hours in the hospital.

I don't use cutting needles in OB patients at all. Do you guys? My preference is for a 25 gauge whitacre whenever possible but will use a 22 gauge whitacre with the really big women. At my institution we deliver about 3,000 babies per year. The C-section rate is around 25-30% (large no pay/medicaid population) so we are familiar with post dural puncture headaches. Over the past ten years we have done ONE blood patch when a 25 gauge whitacre needle was used for a mild headache (the woman wanted the patch). This statement can not be made in the old days when 25 gauge Q needles were used regularly. There were many patches for headaches on these patients.

Blade

Very nice. So you proceeded without any other labs and a PLT of 83?

This woman was huge. I would have never succeeded with a 25g spinal needle. The 22g needle is easier but it increases their risk of a spinal HA (I know you already know this).

To minimize the possibility of the PDPH....I use an epidural needle as an introducer, when in the epidural space float a 5 inch 25 or 27g spinal whitacre needle for the spinal dose. For me, this works great because I get a better feel of where I am with the epidural needle....thus less moving back and forth. How deep was the epidural space....about 12-13cm?


I once had a woman so huge after I pushed the epidural needle into place, when I turned to grab the spinal needle the epidural needle disappeared into her back fold.

For nausia....8mg zofran to everyone prior to spinal. If that fails, 2-3cc's of propofol works like majic.

 

[Huktonfoniks]

given that the nausea post spinal is often secondary to a drop in blood pressure, propofol may not be the best option. I prefer to treat the cause rather than the symptom of nausea.

 

[rmh149]

given that the nausea post spinal is often secondary to a drop in blood pressure, propofol may not be the best option. I prefer to treat the cause rather than the symptom of nausea.

True. I usually hit them with ephedrine and the small amounts of propofol. The ephedrine fixes the cause...but not fast enough. It seems to me that the propofol is faster....and the small amount doesnt noticeably drop the BP further. It is a very transient fix however. But it works long enough to correct the hypotension.

 

[BLADEMDA]

Very nice. So you proceeded without any other labs and a PLT of 83?

This woman was huge. I would have never succeeded with a 25g spinal needle. The 22g needle is easier but it increases their risk of a spinal HA (I know you already know this).

To minimize the possibility of the PDPH....I use an epidural needle as an introducer, when in the epidural space float a 5 inch 25 or 27g spinal whitacre needle for the spinal dose. For me, this works great because I get a better feel of where I am with the epidural needle....thus less moving back and forth. How deep was the epidural space....about 12-13cm?


I once had a woman so huge after I pushed the epidural needle into place, when I turned to grab the spinal needle the epidural needle disappeared into her back fold.

For nausia....8mg zofran to everyone prior to spinal. If that fails, 2-3cc's of propofol works like majic.

Your Spinal needle through the Epidural needle sounds fine. But, statistically my headaches from the 22G whitacre is going to be just as low as your Epidural needle plus spinal approach because you run the risk of an 18G dural puncture every 500 or so sticks. This would be similar to the headache complaints in this population but in my experience those headaches with a 22G whitacre needle in the EXTREME MORBIDLY OBESE are mild.

Blade

 

[chimichanga]

please indulge this long time ED nurse and nursing instructor...

(and pardon my ignorance)

I worked last nite, and read Blade's thread on his case presentations...

Holy ****...I personally had NO idea what anesthesiologists did for a living...I seriously thought it was gas, propofol, and airway management...

I was amazed at the total patient management performed during a surgical procedure...

An ER doc, intensivist, and pulmonologist, all wrapped into one friggin' cowboy doc...

You've got my props...

Now that I think about it, who else would manage all of the "other stuff" that happens, outside of a surgeon's realm?

You!

That being said, I do understand the territorialism displayed here towards CRNAs (curiously, AAs are omitted from the bashing - I don't know enough about what the differences are, if any)...Be equal in midlevel bias/disrespect though (what's up sensei? )...

As an ER RN, I realize I have 1/10 the knowledge of any ER doc...But we cannot perform without each other...

You cannot do your job without the rest of the team...

You must admit, armygas, et al, can adequately do what they do (hopefully simpler stuff, inasmuch as an NP/PA sutures, does paps, defers to the doc when necessary, etc) safely...They seem to, at the very least, respectfully "hang" in your discussions...

Hopefully they know their limitations...

I know I do...

A good doc will listen to his ancillary staff, and take it for what it's worth, and apply what makes sense (hopefully the nurse's intention is in the pts' best interest, not their own)

My pont is, enough with the bashing of each other...it seems (in my personal experience) to serve no one...

 

[Planktonmd]

please indulge this long time ED nurse and nursing instructor...

(and pardon my ignorance)

I worked last nite, and read Blade's thread on his case presentations...

Holy ****...I personally had NO idea what anesthesiologists did for a living...I seriously thought it was gas, propofol, and airway management...

I was amazed at the total patient management performed during a surgical procedure...

An ER doc, intensivist, and pulmonologist, all wrapped into one friggin' cowboy doc...

You've got my props...

Now that I think about it, who else would manage all of the "other stuff" that happens, outside of a surgeon's realm?

You!

That being said, I do understand the territorialism displayed here towards CRNAs (curiously, AAs are omitted from the bashing - I don't know enough about what the differences are, if any)...Be equal in midlevel bias/disrespect though (what's up sensei? )...

As an ER RN, I realize I have 1/10 the knowledge of any ER doc...But we cannot perform without each other...

You cannot do your job without the rest of the team...

You must admit, armygas, et al, can adequately do what they do (hopefully simpler stuff, inasmuch as an NP/PA sutures, does paps, defers to the doc when necessary, etc) safely...They seem to, at the very least, respectfully "hang" in your discussions...

Hopefully they know their limitations...

I know I do...

A good doc will listen to his ancillary staff, and take it for what it's worth, and apply what makes sense (hopefully the nurse's intention is in the pts' best interest, not their own)

My pont is, enough with the bashing of each other...it seems (in my personal experience) to serve no one...

If you need to know more about the CRNA issue go to http://www.aana.com/
You will find it clearly stated, all over their web site, that they are the sole and only provider of anesthesia in this country and there is absolutely no need for anesthesiologists under any circumstances.
You will find that they purposefully "modified" historical and scientific facts to serve their agenda.
Why don't you also watch these 2 videos:
http://www.psanes.org/HB_1256.html

I actually think that you know these things, you are just trying a different more suddle approach to start a new Nurses versus Doctors debate.

 

[rmh149]

Chimichanga, dont worry. There are those that will continue to hate, disrespect and try to end the practice of CRNA's (and vice versa for that matter). I dont fault them for defending their profession. If I were in their shoes I would probably do the same....probably not as harsh though. If I said I wouldnt I would be a hypocrite.

CRNA's will continue to post here and hopefully it will stay clinical. But sometimes a small fight will break out. I try (not always successful) to ignore those posts. I will answer the legitimate questions related to the practice of CRNA's. But it is difficult for some to maintain a professional debate without getting juvenile....as you can probably see (and I am not completely innocent). Who cares...the benefit of the threads outweighs the negative, in my opinion.

I like to compare it to democrats and republicans. you may hate one party...but the two together provide a ballance. As much as I would want to I wouldnt ever choose to kill the ballance for my own benefit.

That being said, Blade started an awesome thread with great clinical situations. I would hate for this to get locked due to another fight going nowhere.

Blade...I'm hoping you have another case to present?

 

[foil]

Calling Blade..........

 

[SouthSideSteve]

dont start that sh.it in this thread too. Your post added nothing to this thread and will more than likely end with it being locked. gj.

 

[jetproppilot]

I agree with you. After getting the second platelet number of 83,000 I called the OB attending. After discussion we agreed to proceed with a C-section in about 1 hour. We also agreed that I would get 30 minutes to do Regional/Spinal on her. If for some reason the First spinal was inadequate then a second attempt at Regional would be allowed.

The MGSO4 bolus and drip was not doing much for the BP. BP=195/103.
Thus, we agreed a C-Section was in order.

After bringing her to the O.R. I placed her in the sitting position. Finding midline was a challenge but I proceeded with the usual 25 gauage whitacre needle plus introducer. No luck. Despite thousands of spinals this lady was tough. So, I switched to a 22 gauge whitacre needle and on the next attempt clear CSF was obtained. I injected the 11 mg or so of Bupivicaine plus Dextrose and 0.25 mg of Duramorph. The pateint was placed supine with usual roll under her right side. A good level of T4 was obtained and the case proceeded with her belly being taped up.

Only about three doses of Phenyephrine 100ug were required during the case. Suprising considering her preoperative BP and the T4 level. She did get nauseated during the case right after the spinal block was placed.
Baby Female delived 9/10 apgars and the case went well.

I have found that the extremely obese rarely get a headache with a 22 gauge whitacre needle. If they do get a headache it is usually quite mild and resolves in a few days. This lady did not get a headache at all and stayed 96 hours in the hospital.

I don't use cutting needles in OB patients at all. Do you guys? My preference is for a 25 gauge whitacre whenever possible but will use a 22 gauge whitacre with the really big women. At my institution we deliver about 3,000 babies per year. The C-section rate is around 25-30% (large no pay/medicaid population) so we are familiar with post dural puncture headaches. Over the past ten years we have done ONE blood patch when a 25 gauge whitacre needle was used for a mild headache (the woman wanted the patch). This statement can not be made in the old days when 25 gauge Q needles were used regularly. There were many patches for headaches on these patients.

Blade

With a lady that big, I dont even try with a 25 gauge.

Right to the 22 gauge.

In my experience, for some reason morbidly obese parturients rarely get spinal headaches....and I always use a 22" on them.....come to think of it, I've never had to do a blood patch on one of them.

 

[militarymd]

Okay,

So if I decide to wait 24 hours until giving the steroids and focus on optomizing fluid/volume in this patient that is acceptable? After all, he may respond nicely to this therapy.

I have been using SINGLE dose Etomidate for Induction of Critically ill patients for a long time-thousands of cases- with no apparent increase in mortality.

In your opinion, Etomidate is Contraindicated in septic patients from the E.R.?
What about low dose etomidate (10-12 mg or so) for trauma? I thought that MANY still use etomidate in these situations?

Blade

Do you follow your patients out 60 days, 90 days, 6 months? I suspect not...as an intensivist, I don't follow them that far out.

There is data to suggest that single dose use increases these long term end points...although the data is not strong, I would tend to believe it just because of the issues that relate to steroid metabolism is sepsis/critical illness

 

[militarymd]

fat prego pre=-e gets intrathecal catheter ASAP in my book.

 

[rmh149]

fat prego pre=-e gets intrathecal catheter ASAP in my book.

Just curious....why?

What kind of kit do you use?