Blade's Cases

[BLADEMDA]

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I thought this would be a nice change from my political threads. I have dozens of cases over the past years which you might find interesting or worth discussing.

Please feel free to ask questions, post comments or simply ignore me.

Blade

 

[jetproppilot]

I thought this would be a nice change from my political threads. I have dozens of cases over the past years which you might find interesting or worth discussing.

Please feel free to ask questions, post comments or simply ignore me.

Blade

Please consider moving your wealth of clinical info to the public forum. 👍

 

[BLADEMDA]

Here is my first case. I did this cases recently and it shows some of hazards of short, SDS cases.

53 year old Morbidly Obese White Male for Bronchoscopy under General. Pulmonary Physician doesn't like MAC for these case and he usually takes 20 minutes.

Here are a few Medical facts about the patient:

1. Morbidly Obese 130 Kg, 5'11''
2. STable Angina, Cardiac Cath in 2000 (negative) NO change in his symptoms
3. Post -Polio Syndrome getting worse each year. Now wheel chair bound with lower extremity weakness. No dysphagia per patient. Previous back operation 20 years ago
4. IDDM
5. HTN
6. GERD (asymptomatic with H2 blocker and proton pump inhibitor)
7. Gout
8. COPD (2ppd for 30 years, quit last week)
9. Recent CXR shows ? Left lower lobe infiltrate
10. Patient SNORES like heck at home and not sure about his breathing at night
11. Scheduled to go home today and wants BIGGY MEAL after the procedure

MEDS:

TOPROL XL
INSULIN
ALLOPURINOL
LISINOPRIL
ZANTAC
PREVACID
PROVENTIL/ALBUTEROL as needed
IMDUR


EKG; NSR
LAbs: Normal NO left shift, normal WBC, No fever

Well, what do you do? Remember, the guy is expecting to go home shortly after the case and wants a biggy meal via the drive thru.

I did the case and it went fine. I will post what I did and let you criticize (I would do the same thing again though) my approach tomorrow.

Blade

 

[Noyac]

My first thoughts are RSI with rocuronium.

Pt will have to wait a little bit longer b/4 going home. But he will go home today.

Second thought, if airway looks to be somewhat difficult I would do awake FOB. And this will take less roc therefore make the recovery shorter.

I avoid Suxx in these pts. Not sure if its warranted but I still avoid it nonetheless.

 

[VentdependenT]

Awake FOI if his airway looks like poo.

If not poo then he gets gets roc RSI. gotta wait then you gotta wait. too bad. I would have FOI in room with an LMA 5 hanging around somewhere.

In this case the Awake may be a better option because you dont need to give a full RSI dose of Roc. Just start numbing him up in holding and give him some versed and IM glyco. Pop the trans-tracheal in as soon as he hits the bed. Propofol and then 20 of roc.

Kablammo

I'd probably suck his guts out too after he goes beddy bye.

 

[CremeSickle]

Thank you blade for adding this.

I look at this guy and see a potential cluster F..

Im with vent. This guy is the prime candidate for FOI. A little lido neb and gargle then go to it. I think its the safest approach with the morbidly obese.

On a couple of occasions i have used 10-20 of prop. during the FOI to sedate them a little when im about to hit the glottis with the scope. I typically avoid more than 1 of versed in these patients and I have been told im very conservative. I was burnt once and had to rescue an airway on a morbidly obese pt who i gave 2 of versed to prior to case then quickly obstructed then was near impossible to bag (short thick neck HEAVY head ALOT of soft tissue).

What other meds do people like with FOI?

 

[jetproppilot]

Here is my first case. I did this cases recently and it shows some of hazards of short, SDS cases.

53 year old Morbidly Obese White Male for Bronchoscopy under General. Pulmonary Physician doesn't like MAC for these case and he usually takes 20 minutes.

Here are a few Medical facts about the patient:

1. Morbidly Obese 130 Kg, 5'11''
2. STable Angina, Cardiac Cath in 2000 (negative) NO change in his symptoms
3. Post -Polio Syndrome getting worse each year. Now wheel chair bound with lower extremity weakness. No dysphagia per patient. Previous back operation 20 years ago
4. IDDM
5. HTN
6. GERD (asymptomatic with H2 blocker and proton pump inhibitor)
7. Gout
8. COPD (2ppd for 30 years, quit last week)
9. Recent CXR shows ? Left lower lobe infiltrate
10. Patient SNORES like heck at home and not sure about his breathing at night
11. Scheduled to go home today and wants BIGGY MEAL after the procedure

MEDS:

TOPROL XL
INSULIN
ALLOPURINOL
LISINOPRIL
ZANTAC
PREVACID
PROVENTIL/ALBUTEROL as needed
IMDUR


EKG; NSR
LAbs: Normal NO left shift, normal WBC, No fever

Well, what do you do? Remember, the guy is expecting to go home shortly after the case and wants a biggy meal via the drive thru.

I did the case and it went fine. I will post what I did and let you criticize (I would do the same thing again though) my approach tomorrow.

Blade

Polio stuff makes these patients sensitive to everything....and their recovery is longer....so doing this case in an SDS is a stretch...but hey, I'm game...

Less drugs is more in this guy.

Make sure he's beta blocked.

No opiods. No muscle relaxant....yeah, you can use depolarizer/non depolarizer but with the potential for prolonged effect I'd at least try to not use them.

He's asymptomatic on his GERD meds. GERD doesnt bother me unless they complain of postural GERD symptoms.

Monitors on, pre02, reverse T-berg.

Propofol 200mg.

Oral airway in when his gag is gone.

Crank the sevo to max, keep your 02 flow at 10 liters/min, and give him small, non-gastric-insufflating tidal volumes for a cuppla minutes. Use two people if you have to...one dude holding the mask, the other squeezing the bag.

When you are satisfied that he's got some gas on board insert da snorkel. He shouldnt fight if you've got enough gas on board because the gas + propofol should be enough. If he fights, now you dont have a choice. The 20mg roc that Noy and Venty mentioned sounds like a good dose. But again, your life will be easier if you can avoid it.

Reduce sevo to 5%, turn the bed, attach bronch-side-port-thinghy.

Keep him still with gas. Reduce sevo to 3% after five minutes or so if able.

If he gets hyperdynamic, use a beta blocker of your choice.

Suck his stomach out with OGT at end before extubating like Venty said.

If you had to use rocuronium, give full reversal.

Extubate, to PACU.

Have a Mexican Pizza, two bean buritos, three Taco Supremes, and large mountain dew waiting.

Have him read the-funnies on the side of the Fire Sauce packets to pass the time.

Between bites, he's probably gonna need to suck on a nebulizer with all the instrumentation done to a very hyper-reactive broncho-pulmonary tree.

 

[cchoukal]

What other meds do people like with FOI?

At the U of Chicago we have a study going comparing fent/midaz vs dexmedetomidine for FOBI sedation. I suspect the outcome will show they're about the same but one is dramatically more expensive.

 

[Planktonmd]

Good topical anesthesia + transtracheal block.
Glycopyrolate IV.
a touch of Midazolam and Fentanyl for sedation.
Awake fiberoptic intubation.
Spray the carina with local through the scope after intubation.
minimal anesthesia for the procedure after that, maybe a propofol infusion and small increments of fentanyl.
No muscle relaxants.
He will do great.
The main issue with post polio syndrome is that each general anesthetic can make them worse.

 

[CremeSickle]

How many people are doing transtracheal blocks? It seems to me that theya re discouraged where I am.

How about your area?

 

[2ndyear]

I really like the Dex for awake fiberoptics if I have the time. To really get the effect the loading dose is nice and this takes 10 minutes. It's great because FOI is easier if the pt is breathing and on dex they will be. Still $56 a crack though.

I do the transtracheal whenever I can, so most true awake FOI. Mainly because I'm a resident though and I want all of the experiences I can at needling the cricothyroid membrane. What I haven't done enough of is the 'other' blocks of the airway.

 

[Planktonmd]

How many people are doing transtracheal blocks? It seems to me that theya re discouraged where I am.

How about your area?

They can discourage them all day long I will still do them because they work.

 

[Mman]

I have found that 1-2 of Midaz plus maybe 50 of Fentanyl and a dex infusion works quite well.

 

[militarymd]

Here is my first case. I did this cases recently and it shows some of hazards of short, SDS cases.

53 year old Morbidly Obese White Male for Bronchoscopy under General. Pulmonary Physician doesn't like MAC for these case and he usually takes 20 minutes.

Here are a few Medical facts about the patient:

1. Morbidly Obese 130 Kg, 5'11''
2. STable Angina, Cardiac Cath in 2000 (negative) NO change in his symptoms
3. Post -Polio Syndrome getting worse each year. Now wheel chair bound with lower extremity weakness. No dysphagia per patient. Previous back operation 20 years ago
4. IDDM
5. HTN
6. GERD (asymptomatic with H2 blocker and proton pump inhibitor)
7. Gout
8. COPD (2ppd for 30 years, quit last week)
9. Recent CXR shows ? Left lower lobe infiltrate
10. Patient SNORES like heck at home and not sure about his breathing at night
11. Scheduled to go home today and wants BIGGY MEAL after the procedure

MEDS:

TOPROL XL
INSULIN
ALLOPURINOL
LISINOPRIL
ZANTAC
PREVACID
PROVENTIL/ALBUTEROL as needed
IMDUR


EKG; NSR
LAbs: Normal NO left shift, normal WBC, No fever

Well, what do you do? Remember, the guy is expecting to go home shortly after the case and wants a biggy meal via the drive thru.

I did the case and it went fine. I will post what I did and let you criticize (I would do the same thing again though) my approach tomorrow.

Blade

I know what the definitions are, but come on.....that's our average patient dimensions.

 

[militarymd]

propofol

LMA

Sevo..

Bronch...

go home.

no narcs...no benzos...no local...no bs....no nothing else.

done it a million times...well...,maybe not a million, but you get my point.

 

[BLADEMDA]

propofol

LMA

Sevo..

Bronch...

go home.

no narcs...no benzos...no local...no bs....no nothing else.

done it a million times...well...,maybe not a million, but you get my point.

Mil MD,

I did it the same way but first I gave some premeds:

1. Proventil RX in holding
2. Zantac 50 mg IV
3. Reglan 10mg IV
4. Solumderol 125 mg IV (debated this one)

Then, Propofol Induction with size 5 LMA. Pulmonologist not thrilled with LMA as he prefers E.T. tube. But, in this case "he worked with me" to avoid a long PACU stay or 23 hour admit. Patient did fine.

I have had two other cases (ORTHO) with Post Polio Syndrome. I avoid SUX in these cases so if muscle relaxant is used go with LOW DOSE Rocuronium.
However, I had a patient where 20 mg Rocuronium lasted for 2 hours (one single dose given upfront) and he still was weak in PACU. I decided to request 23 hour stay for him. Thus, I am wary of this syndrome in SDS patients.

Tomorrow, another real world case.

Blade

 

[thegasman]

Mil MD,

I did it the same way but first I gave some premeds:

1. Proventil RX in holding
2. Zantac 50 mg IV
3. Reglan 10mg IV
4. Solumderol 125 mg IV (debated this one)

Then, Propofol Induction with size 5 LMA. Pulmonologist not thrilled with LMA as he prefers E.T. tube. But, in this case "he worked with me" to avoid a long PACU stay or 23 hour admit. Patient did fine.

I have had two other cases (ORTHO) with Post Polio Syndrome. I avoid SUX in these cases so if muscle relaxant is used go with LOW DOSE Rocuronium.
However, I had a patient where 20 mg Rocuronium lasted for 2 hours (one single dose given upfront) and he still was weak in PACU. I decided to request 23 hour stay for him. Thus, I am wary of this syndrome in SDS patients.

Tomorrow, another real world case.

Blade

Alternative could be fast trach/ intubating lma and you could get ett for your pulmonologist without prolonging stay.

 

[BLADEMDA]

Alternative could be fast trach/ intubating lma and you could get ett for your pulmonologist without prolonging stay.

There are a lot of ways to do the case. My goal each and every day is to do each case safely, quickly and with no morbidity. I work in a high volume practice where speed and efficiency really do matter.

I will post many more cases. I will let you decide how to approach them. In addition, I will inform you what I did for the case and how that particular case went intraop and postop. Perhaps, I may add something of value to this forum or, perhaps not.

Blade

 

[jetproppilot]

Mil MD,

I did it the same way but first I gave some premeds:

1. Proventil RX in holding
2. Zantac 50 mg IV
3. Reglan 10mg IV
4. Solumderol 125 mg IV (debated this one)

Then, Propofol Induction with size 5 LMA. Pulmonologist not thrilled with LMA as he prefers E.T. tube. But, in this case "he worked with me" to avoid a long PACU stay or 23 hour admit. Patient did fine.

I have had two other cases (ORTHO) with Post Polio Syndrome. I avoid SUX in these cases so if muscle relaxant is used go with LOW DOSE Rocuronium.
However, I had a patient where 20 mg Rocuronium lasted for 2 hours (one single dose given upfront) and he still was weak in PACU. I decided to request 23 hour stay for him. Thus, I am wary of this syndrome in SDS patients.

Tomorrow, another real world case.

Blade

Why Proventil in holding? Was there evidence of active bronchospasm?

Why Zantac/reglan? You said patient was asymptomatic on his GERD meds.

Not arguing for arguments sake.

But C'mon, Blade.

Albuterol is a rescue medicine.

Its use prophylactically is complete voodoo.

As is Zantac/reglan for patients with asymptomatic GERD.

 

[jetproppilot]

My goal each and every day is to do each case safely, quickly and with no morbidity. I work in a high volume practice where speed and efficiency really do matter.

As do Mil and I, Slim.

 

[BLADEMDA]

Why Proventil in holding? Was there evidence of active bronchospasm?

Why Zantac/reglan? You said patient was asymptomatic on his GERD meds.

Not arguing for arguments sake.

But C'mon, Blade.

Albuterol is a rescue medicine.

Its use prophylactically is complete voodoo.

As is Zantac/reglan for patients with asymptomatic GERD.

Sure, I understand your point of view. Your a minimalist who wants SOLID evidence before using any pre-med. I, on the other hand, don't mind giving CHEAP pre-meds with the understanding that they MAY help avoid a problem.

I have had many mild aspirations in my career (SDS cases). NEVER had one with Zantac and Reglan on board before the case. So, I am inclined to use the medications as part of my regimen.

The Solumedrol and Proventil were given to DECREASE the possibility of Bronchospasm post-operatively. You could argue both were unnecessary and over-kill. I used them in this case because he gives a history of some reactive airway disease.

Blade

 

[jetproppilot]

Sure, I understand your point of view. Your a minimalist who wants SOLID evidence before using any pre-med. I, on the other hand, don't mind giving CHEAP pre-meds with the understanding that they MAY help avoid a problem.

I have had many mild aspirations in my career (SDS cases). NEVER had one with Zantac and Reglan on board before the case. So, I am inclined to use the medications as part of my regimen.

The Solumedrol and Proventil were given to DECREASE the possibility of Bronchospasm post-operatively. You could argue both were unnecessary and over-kill. I used them in this case because he gives a history of some reactive airway disease.

Blade

I respect your stance.

So tell me.

How does a beta-two-inhaled agonist, who's half-life is extremely short, when used prophylactically, help a future bronchospasm, when said-feared-future bronchospasm is many minutes away?

Hey, I'm not above practicing Voodoo where said Voodoo is anecdotally, but not scientifically proven.

But a pre-op albuterol treatment does nothing on a non wheezing patient, dude.

Except waste time.

And money.

Yeah, the albuterol is inexpensive.

But if you are an owner of the SDS, how much does it cost to have an RN waste her time giving a needless resp treatment, over a years time, to all the people you think need a resp treatment?

I'd say no less than THIRTY LARGE.

Compound that by the time needlessly taken by RNs going to the Pixus, pulling out needless medicines, and injecting/inhaling said-needless medicines, you're talking about thousands and thousands of dollars in manpower.

That really isnt needed.

 

[sdn1977]

Interesting discussion....& I obviously can't add anything to the anesthesia choices. But, I will add a few thoughts to the albuterol discussion, since this has changed in recent months.

Blade - you didn't mention if your albuterol tx is by nebulizer or mdi. Some RNs do nebulizers, but my institutions use RTs for that. There are very few non-HFC albuterol mdi's around....only if the wholesalers have them in stock. They'll be entirely out of production by Dec of this year....so..the $$ will be double.

Currently, HFC albuterol mdi's run about $0.40/gm (some more, some less depending on contracts). So, an mdi will "cost" the institution about $7.50 - small change. The newer non-HFC products "cost" about twice that & will become the routine product available. Except, someone has to give it - the rn or rt...or perhaps the pt himself. If the rn or rt administers the drug, the "cost" increases significantly due to the labor itself (figure approx 15 min/tx - $45/hr salary (includes benefits).....much more than the cost of the drug....without even including the labor costs you don't see....in the pharmacy.

Now....studies have shown approx 80% of an inhaled albuterol mdi is doposited in the oropharynx & subsequently absorbed into the GI tract then the blood. The albuterol is a mixture of the R-enantiomer which produces brochodilation & the S-enantiomer which can increase airway reactivity, oddly enough.

Its been shown that the kinetics of the R & S enantiomers is significantly different with the S enantiomer being retained preferentially in the lungs while the R-enantiomer tends to be more rapidly absorbed into the circulation via the GI route, although the portion which is actually delivered to the lungs is immediately active - thus rapid bronchodilation. The R-enantiomer portion absorbed into the lung peaks at 15-30 min & most of it is excreted within 30 min of the peak. The longer effects which are sometimes seen are due to the GI absorption of the R enantiomer - somewhat like giving oral albuterol. But...the S-enantiomer stays in the lung tissue and gets elminated much more slowly.

This gradual accumulation of the S-enantiomer, with slower elimination, is the basis for speculation as to why there tends to be a paradoxical increase in airway reactivity in those pts who regularly use (& abuse) albuterol inhalers.

So...not sure that this is even germain to your patient....just an interesting look at albuterol & why some like pretreatment & some don't. As a pharmacist - if you're going to give a pretx....I guess I'd rather you do it via an mdi. That actually "costs" less than the tubing, etc...which goes with the nebulizer even though the nebulized albuterol cost pennies. Since we're not reimbursed by line item used, even though it may cost my dept a bit more...I have to figure the cost of other depts as well.

 

[jeesapeesa]

have you ever done an albuterol treatment and wake up someone who is snoring and obviously in NO respiratory distress, but because the pulmonologist orders Q4 around the clock? as an rt, i have and it's pretty pointless.

 

[BLADEMDA]

I respect your stance.

So tell me.

How does a beta-two-inhaled agonist, who's half-life is extremely short, when used prophylactically, help a future bronchospasm, when said-feared-future bronchospasm is many minutes away?

Hey, I'm not above practicing Voodoo where said Voodoo is anecdotally, but not scientifically proven.

But a pre-op albuterol treatment does nothing on a non wheezing patient, dude.

Except waste time.

And money.

Yeah, the albuterol is inexpensive.

But if you are an owner of the SDS, how much does it cost to have an RN waste her time giving a needless resp treatment, over a years time, to all the people you think need a resp treatment?

I'd say no less than THIRTY LARGE.

Compound that by the time needlessly taken by RNs going to the Pixus, pulling out needless medicines, and injecting/inhaling said-needless medicines, you're talking about thousands and thousands of dollars in manpower.

That really isnt needed.

Jet,

I don't use a lot of Albuterol preoperatively- only about once per month. I have never used it preoperatively in a SDS Center (privately owned) only the hospital setting. I doubt 12 treatments costs anywhere near $30,000.

I chose the Proventil RX (I actually used his MDI) just as a precaution. Perhaps, overkill and not needed at all.

As for the Reglan he is a perfect candidate for the drug. Obese, IDDM with Gerd. As I have mentioned before Reglan works quickly (1-3 minutes) and is very effective in reducing gastric volume in Diabetics (peer reviewed study).
I use this drug frequently for the right subset of patients.

Blade

 

[Planktonmd]

Post Polio Syndrome is problematic not only for using Sux or not, it tends to exacerbate with general anesthesia even in the absence of muscle relaxants. In a way it's comparable to chronic fatigue syndrome.
These patients also, very frequently, have laryngeal muscles dysfunction which increases the risks for post-anesthetic apnea, aspiration, and vocal cord paralysis.

 

[BLADEMDA]

Okay, here comes another real world case.

I get a call from one of the Orthopedic Surgeons in the morning that he needs my help to do a difficult case. The patient is in the E.R. ad he needs to do the case in a few hours. He wants to work the case into his schedule.
He is a fast, efficient, experienced Surgeon with a high volume practice.

Here is the case as described to me over the phone.


63 Year old white Female in the E.R. with a severe forearm fracture (she fell). Her husband is with her and he is a retired Neurologist (former active staff). She has not eaten for 6 hours and has basic lab work, CXR, EKG, etc.

PMH:

1. Obese- 125 Kg, 5'2"
2. COPD- 2ppd quit 5 years ago
3. Myasthenia Gravis- diagnosed at age 55
4. History of Pneumonia 3 years ago- in hospital for 5 days, not intubated but needed BiPAP for first 24 hours of stay.
5. GERD- stable, asymptomatic on meds
6. 0xygen at night- 2 liters
7. Borderline HTN per husband


PSH: Appendectomy as child

Meds:

1. Pyridostigmine (mestinon)
2. Mycophenalate Mofeti (cellcept)
3. Pantoprazole (Protonix)
4. Losartan (Cozaar)

Labs:

EKG: NSR, LVH
CXR: COPD
Saturation: 92% on 2liters
CBC: Normal
Chem-7: Normal
PT/PTT: INR=1.7 PTT-WNL


Orthopod and patient really want REGIONAL. I discussed risks/benefits with patient and husband and BOTH want Regional with NO intubation.
My exam of the patient shows a morbidly obese female with a very BIG Abdomen and HUGE arms. Her airway looks "easy" but she is very nervous.

Orthopod states Surgery needs to be done today despite increased INR.
Patient, Husband and Surgeon agree to FFP if needed and in-hospital work-up of increased INR. Surgery will be performed today. Husband and patient are TERRIFIED of Intubation/post-operative ventilation and will do ANYTHING to avoid it.

What is your plan? You can order any test needed but need to do the case in 1-2 hours per surgeon (he is calling it an emergency).

Blade

 

[VentdependenT]

LMA eh?

I like your style folks. We have one attending who does do those for bronchs but I havent worked with him. Does em for OLV for vats as well.

My fears for LMA and bronch. Can't deliver decent tidal volumes when the sats go down and the pt's in bronchospasm. Allay my fears and worries oh wise ones.

 

[drrosenrosen]

tx FFP in the ER, get a confirmed INR< 1.3 before starting. US guided interscalene block, no sedation, nasal O2, you'll of course tolerate a lower sat since she lives in the low 90s. Don't see any reason that she needs to be GA/tube, although it doesn't seem like her COPD is that bad. Am I way off?

 

[VentdependenT]

tx FFP in the ER, get a confirmed INR< 1.3 before starting. US guided interscalene block, no sedation, nasal O2, you'll of course tolerate a lower sat since she lives in the low 90s. Don't see any reason that she needs to be GA/tube, although it doesn't seem like her COPD is that bad. Am I way off?

sounds good for a shoulder scope but we're talkin bout a bronchoscopy. 🙂

 

[militarymd]

tx FFP in the ER, get a confirmed INR< 1.3 before starting. US guided interscalene block, no sedation, nasal O2, you'll of course tolerate a lower sat since she lives in the low 90s. Don't see any reason that she needs to be GA/tube, although it doesn't seem like her COPD is that bad. Am I way off?

When someone walks in with an elevated INR with no clear cause...you have to think about 2 things.

1) factor deficiencies.

or

2) circulating anticoagulant

If you have 2), it won't matter how much FFP you give, the INR will still be elevated....

As for clinical significance...if it is something like Lupus anticoagulant....or some similar anti phospolipid type antibody, then it won't matter, because the will likely not bleed...and more likely clot more than you want.

So...giving FFP prior to sending off a 1:1 dilution to check for correction is probably not a good idea because you just exposed the patient to blood components unnecessarily.

As for mechanical ventilation, I would explain to the so-called doctor that his fears are unfounded....This procedure does not enter the abdomen, does not alter the thorax and other pulmonary mechanics, and no lung tissue is being removed....GA is ABSOLUTELY safe.

but I would do an ax block, and reserve the right for GA if necessary...however with GA, I would use a ETT for optimized mechanical support for someone whose pulmonary reserve is decreased.

 

[core0]

When someone walks in with an elevated INR with no clear cause...you have to think about 2 things.

1) factor deficiencies.

or

2) circulating anticoagulant

Snip

You would also have to think about liver failure. Huge person hmm NASH with cirrhosis? Also you would have to consider an acute failure with something like HSV or CMV (I'm assuming if she was bright orange that would have been in the H&P). Finally consider Jets warning about NPO and look at the GI side effects of Mestinon. Interesting case.

David Carpenter, PA-C

 

[militarymd]

You would also have to think about liver failure. Huge person hmm NASH with cirrhosis? Also you would have to consider an acute failure with something like HSV or CMV (I'm assuming if she was bright orange that would have been in the H&P). Finally consider Jets warning about NPO and look at the GI side effects of Mestinon. Interesting case.

David Carpenter, PA-C

Those specific diagnoses fall under "factor deficiencies"......as with others..like nutritional deficiences...bacteria overgrowht...etc.

 

[BLADEMDA]

Mil MD,

You are on the money again. Do you want any more lab tests? TEG is avail. if you want to order it. Do you want Chem-18? One more thing I am EXCELLENT at Axillary Blocks (thousands performed) but there is NO WAy you are going to do a trans-arterial Axillary block on her. She is in a great deal of pain and can not move her arm so a LOT of sedation will be needed for axillary approach. Plus, her arm is the size of JPP's beer budget.

The patient requested NO INTUBATION because she is afraid of post operative ventilation. She is PLEADING not to be intubated if at all possible. Everyone involved understands the risks including bleeding, infection, death, prolonged ventilation etc.

What next o' great one?

Blade

 

[Planktonmd]

tx FFP in the ER, get a confirmed INR< 1.3 before starting. US guided interscalene block, no sedation, nasal O2, you'll of course tolerate a lower sat since she lives in the low 90s. Don't see any reason that she needs to be GA/tube, although it doesn't seem like her COPD is that bad. Am I way off?

You might want to avoid interscalene blocks in someone with severe COPD who requires O2 therapy, because you will definitely get an ipsilateral phrenic nerve block and this will cause her to decompensate.
All other approaches to brachial plexus block are ok, although I would avoid a supraclavicular approach in COPD with emphysema.
The Infraclavicular approach seems to be the most attractive one since it will also cover the tourniquet pain.
If you are not comfortable with Infraclavicular blocks go for an Axillary (avoiding the transarterial technique unless you had fully corrected the coags) and maybe a musculocutaneous nerve block.
As for the coagulopathy I would try to figure out the etiology and treat accordingly before starting but I can live with mild elevation of INR as long the surgeon knows what he is doing and willing to proceed and use a tourniquet.

 

[BLADEMDA]

You might want to avoid interscalene blocks in someone with severe COPD who requires O2 therapy, because you will definitely get an ipsilateral phrenic nerve block and this will cause her to decompensate.
All other approaches to brachial plexus block are ok, although I would avoid a supraclavicular approach in COPD with emphysema.
The Infraclavicular approach seems to be the most attractive one since it will also cover the tourniquet pain.
If you are not comfortable with Infraclavicular blocks go for an Axillary (avoiding the transarterial technique unless you had fully corrected the coags) and maybe a musculocutaneous nerve block.
As for the coagulopathy I would try to figure out the etiology and treat accordingly before starting but I can live with mild elevation of INR as long the surgeon knows what he is doing and willing to proceed and use a tourniquet.

Good response. See previous post. Want any other tests? I agree with you on the approach but bring your "A" game.

Blade

 

[militarymd]

Mil MD,

You are on the money again. Do you want any more lab tests? TEG is avail. if you want to order it. Do you want Chem-18? One more thing I am EXCELLENT at Axillary Blocks (thousands performed) but there is NO WAy you are going to do a trans-arterial Axillary block on her. She is in a great deal of pain and can not move her arm so a LOT of sedation will be needed for axillary approach. Plus, her arm is the size of JPP's beer budget.

The patient requested NO INTUBATION because she is afraid of post operative ventilation. She is PLEADING not to be intubated if at all possible. Everyone involved understands the risks including bleeding, infection, death, prolonged ventilation etc.

What next o' great one?

Blade

My thoughts:

- Surgeon says you have to go, so I assume we're going in a few hours regardless.

- Unexplained elevated INR requires consultation and follow up...so I would get the consultation process started and ask the consultation for any blood work to be ordered prior to me initiating other therapy.

- if based on 1:1 there is evidence of factor deficiency, I would use ffp, if not, I would proceed with the elevated INR.

- I would order a TEG if the consultant wants it. I'm not sure what I would do with the information. Platelet defect....won't cause elevated INR. Factor deficiency...1:1 would give you that info....elevated fibrionlysis.....not going to show up as eleveated INR....so no TEG for me.

- I would pick which ever brachial plexus technique that will most likely succeed and give it a best shot...and do GA if necessary....

- My shop is NOT Burger King, you can't have it the way you want it. You get it like you NEED it.

 

[Planktonmd]

Good response. See previous post. Want any other tests? I agree with you on the approach but bring your "A" game.

Blade

Why is she on immuno-suppressants? (Cellcept)
With this mild elevation of INR and normal PTT, I would treat empirically with 1 or 2 FFP's and proceed to surgery as I mentioned above.
Would not order TEG.

 

[militarymd]

Why is she on immuno-suppressants? (Cellcept)
With this mild elevation of INR and normal PTT, I would treat empirically with 1 or 2 FFP's and proceed to surgery as I mentioned above.
Would not order TEG.

off label use for myasthenia

 

[BLADEMDA]

tx FFP in the ER, get a confirmed INR< 1.3 before starting. US guided interscalene block, no sedation, nasal O2, you'll of course tolerate a lower sat since she lives in the low 90s. Don't see any reason that she needs to be GA/tube, although it doesn't seem like her COPD is that bad. Am I way off?

Please recall that the surgeon wants to do the case in about 2 hours. he has declared it an "emergency" but recognizes you need some time to get her ready for the O.R. Thus, if you order FFP AND a repeat INR this will take at least 2 hours. There is no guarantee the INR will be lower with the FFP. You still need to do the case. After reading Mil MD's post (he is basically correct about the Coag issue) do you want to give the FFP? Interscalene block is a poor choice for two reasons : 1) miss ulnar nerve 10% of the time and in this case you MUST cover this nerve and 2) she has severe COPD with saturation of 92% on 2 liters and an ISB will potentially worsen her resp. status due to ipsilateral phrenic nerve block.

Blade

 

[Planktonmd]

off label use for myasthenia

Ok, thanks

 

[BLADEMDA]

Why is she on immuno-suppressants? (Cellcept)
With this mild elevation of INR and normal PTT, I would treat empirically with 1 or 2 FFP's and proceed to surgery as I mentioned above.
Would not order TEG.

I too did not order the TEG. I did order 2 units of FFP be brought to the operating room just in case but I did not use it (sorry, JPP I am wasting money again). Like Mil MD suggested I told the patient and her husband I could not guarantee anything but would do my best to avoid intubation.

I skipped any further lab work and brought the patient to the holding area for the block.

Blade

 

[rmh149]

Why is she on immuno-suppressants? (Cellcept)

To reduce symptoms of Myasthenia Gravis.

 

[militarymd]

I too did not order the TEG. I did order 2 units of FFP be brought to the operating room just in case but I did not use it (sorry, JPP I am wasting money again). Like Mil MD suggested I told the patient and her husband I could not guarantee anything but would do my best to avoid intubation.

I skipped any further lab work and brought the patient to the holding area for the block.

Blade

How did it work out?


What was the cause of the abnormal INR?

 

[BLADEMDA]

off label use for myasthenia

look up the side-effects of cellcept. It lists increased INR as one.

I didn't know that before this case. I also didn't think about those darn antibodies, lupus anti-coagulants, etc. either BEFORE the case.

Blade

 

[militarymd]

look up the side-effects of cellcept. It lists increased INR as one.

I didn't know that before this case. I also didn't think about those darn antibodies, lupus anti-coagulants, etc. either BEFORE the case.

Blade

I guess I need a new book...I DID look up Cellcept when you first posted, and my book didn't list that as an adverse reaction.

 

[BLADEMDA]

So the lady arrives in holding area for the block. She is very large (125 kg, 5'2" ) and anxious. After placing the appropriate monitors I get ready for my 'A' game. I normally don't bother with U/S guidance very much. I have the basic Sonosite model and NOT the Micromaxx so my pictures are not that great. In this case I decide to use all my avail. resources to improve my odds.

I decide on the InfraClavicular approach. My aresenal includes Nerve Stimulator (Braun), Braun needle 21gauge x 4 inches and U/S machine. While you can't see the cords that well you can see the artery and the spread of the local POSTERIOR to the artery with the basic U/S model.

I lightly sedated the patient with Versed/Fentanyl and did the block. I had a CRNA hold the U/S proble while I did the block. I easily got Medial Cord stimulation and then directed the needle more vertical for Posterior/Radial nerve stimulation. I injected 8 cc at first and the remainder posterior to the artery.
After about 15 minutes the patient had an excellent block and I avoided the artery.

The case took about 2 hours and a low dose propofol infusion was used along with a face mask. The case went well and the patient went home after about 3 days. I found out later that the cause of the increased INR was like Mil MD stated in his post (reason 2). The patient had "something strange" per the Ortho Surgeon that caused her INR to be increased and she was not really at risk of bleeding during the case.

Although the single shot block went well I briefly entertained the idea of a Catheter plus Ropivicaine local infusion for post-operative pain. But, I decided to go with what had the highest chance for success (K.I.S.S.) and just do what I had done many times in the past. The block lasted through the night and the patient did fine with the Dilaudid PCA (per Ortho Surgeon).

Blade

 

[BLADEMDA]

I "googled" this drug and it has a whole list of serious side-effects. The University of Maryland Medical Center states it can cause increased PT and PTT. The LFT's can be increased as well.

I think the patient was on this drug because her husband was a Neurologist. Perhaps, he was trying Cellcept and/or had tried everything else. I didn't get into that long a discussion with him about 'experimental/new' Myasthenic drugs. I do know he had her on 'different drugs' over the past few years looking for the best results.

Blade

 

[BLADEMDA]

Anymore questions/comments about Case 1 or 2 before reading Case number 3?

 

[epidural man]

I thought this would be a nice change from my political threads. I have dozens of cases over the past years which you might find interesting or worth discussing.

Please feel free to ask questions, post comments or simply ignore me.

Blade

Blade,

Excellent cases. I liked the infraclavicular approach. I love that block.

I had a question about your first case. Any thought to using high dose precedex? We have done some suspension laryngoscopy cases with it. It works well. I wonder how a bronch similar to your case would go? The more I use precedex, the more I like it. The down side is a longer recovery. Also, and ILA instead of an LMA might make your pulmonologist a little happier. The tube is wider and probably easier to manuever the scope with it.