C6-7 quadriplegic scheduled for phaco/IOL

[pgg]

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Unfortunately dopamine given IV will get metabolized by MAO and will not reach the basal ganglia.

Didn't know that (not that I'd have tried a dopamine infusion in this patient 😉).

Wonder if you'd get enough upstream flow from a lumbar drain ...

Might have to go transcranial and put the catheter in a ventricle.

 

[Planktonmd]

Didn't know that (not that I'd have tried a dopamine infusion in this patient 😉).

Wonder if you'd get enough upstream flow from a lumbar drain ...

Might have to go transcranial and put the catheter in a ventricle.

Actually the transcranial route is probably more effective, you can also use it to give a local anesthetic and achieve a very high intrathecal anesthetic ideal for cataract surgery.

 

[deleted162650]

Actually the transcranial route is probably more effective, you can also use it to give a local anesthetic and achieve a very high intrathecal anesthetic ideal for cataract surgery.

Intra-ventricular lidocaine is my new go-to anesthetic.

 

[deleted171991]

Intra-ventricular lidocaine is my new go-to anesthetic.

That's too long-lasting for cataract surgery. Chlorprocaine is better.

 

[deleted87051]

Intra-ventricular lidocaine is my new go-to anesthetic.

Aren't you concerned about transient brain irritation?

 

[skypilot]

Would the superstars be so kind and stop shaming people for asking questions? A lot of anesthesiology knowledge is experience (it cannot be learned just from books). So knowing the right answer doesn't necessarily say that you guys are better, just more experienced, or that you had better training (and better colleagues who helped you initially, in the real world). Plus a quadriplegic is an exotic patient, not B&B, and he asked pretty pertinent questions (except for not planning for an LMA). It's not like the OP gave the patient sux.

My solution would be to attempt sedation with carefully titrated good doses of midaz or precedex, on top of topical, ready to switch to GA-LMA if needed. I think that could take care of the spasms. Avoid propofol and anything that allows sudden (confused) wake up and movement (you want a groggy, slowly moving patient). And avoid too much sedation, because even snoring will disturb the surgical field. So if the spasms don't go away, just go to GA early. Immobilize the head generously with tape.

I always bounce unusual cases off my colleagues since most of my work is bread and butter. Who knows? Someone might come up with a novel solution that I haven't considered or maybe just discussing the case will help me to dust off the cobwebs and come up with a new solution of my own. There are always many combinations that will work. Even the simplest cases have many variables that you can modify to improve the intra-op or post-op results, the speed of the case, the cost of the case, the patient experience etc. I feel like that is the difference between following a protocol and practicing the art of Anesthesia.

 

[deleted87051]

Even the simplest cases have many variables that you can modify to improve the intra-op or post-op results, the speed of the case, the cost of the case, the patient experience etc. I feel like that is the difference between following a protocol and practicing the art of Anesthesia.

And many variables make no difference whatsoever but we like to pretend that they do and debate endlessly about them. It's often more metaphysical than scientific.

 

[Planktonmd]

That's too long-lasting for cataract surgery. Chlorprocaine is better.

Good point.

 

[Planktonmd]

Aren't you concerned about transient brain irritation?

Transient brain irritation syndrome can definitely be a problem with the intracerbral anesthetic techinique, but it's a small price to pay to achieve perfect surgical conditions for the cataract surgery.

 

[deleted162650]

Aren't you concerned about transient brain irritation?

When u really get right down to it, isn't that what all GA is.

 

[cbest]

Perhaps contacting the patient's SCI physiatrist regarding the current state of his spasticity would be a good first step. Medical issues possibly exacerbating his spasticity need to be ruled out, then perhaps meds can be titrated to improve control. Don't know if there would be concern about Botox injections in weeks leading up for possible surgery.

 

[Noyac]

Perhaps contacting the patient's SCI physiatrist regarding the current state of his spasticity would be a good first step. Medical issues possibly exacerbating his spasticity need to be ruled out, then perhaps meds can be titrated to improve control. Don't know if there would be concern about Botox injections in weeks leading up for possible surgery.

Why would you not be able to gather this directly from the pt?

 

[cbest]

Why would you not be able to gather this directly from the pt?

Because tetraplegic (yes, that's the proper term... not quadriplegic) patients may not know if they have a UTI, PNA, ingrown toenail, stool impaction, pressure ulcer, etc that can exacerbate spasticity. And the patient won't be the one titrating their baclofen, etc.


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[Noyac]

Because tetraplegic (yes, that's the proper term... not quadriplegic) patients may not know if they have a UTI, PNA, ingrown toenail, stool impaction, pressure ulcer, etc that can exacerbate spasticity. And the patient won't be the one titrating their baclofen, etc.


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You understand that this is a 20 minute case, right? And it has as close to zero stimulation as any case there ever was. If we are doing a BKA then ok Let's talk. But for this case I'm not wasting your time or mine. I have probably 10 more cases to do before lunch.

 

[cbest]

You understand that this is a 20 minute case, right? And it has as close to zero stimulation as any case there ever was. If we are doing a BKA then ok Let's talk. But for this case I'm not wasting your time or mine. I have probably 10 more cases to do before lunch.

Sure thing bud - not my patient! Good luck!


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[sevoflurane]

Unfortunately dopamine given IV will get metabolized by MAO and will not reach the basal ganglia. It would be better to infuse Dopamine directly into the CSF using a lumbar drain, and you should preferably combine that with a good xenon inhaled anesthetic, which apparently helps with the tremor https://www.michaeljfox.org/foundation/grant-detail.php?grant_id=1099
This will be a perfect anesthetic for that cataract surgery. 👍

I'm crying. 🤣

 

[sigrhoillusion]

Unfortunately dopamine given IV will get metabolized by MAO and will not reach the basal ganglia. It would be better to infuse Dopamine directly into the CSF using a lumbar drain, and you should preferably combine that with a good xenon inhaled anesthetic, which apparently helps with the tremor https://www.michaeljfox.org/foundation/grant-detail.php?grant_id=1099
This will be a perfect anesthetic for that cataract surgery. 👍

What about a rocuronium infusion?

 

[Mman]

Because tetraplegic (yes, that's the proper term... not quadriplegic) patients may not know if they have a UTI, PNA, ingrown toenail, stool impaction, pressure ulcer, etc that can exacerbate spasticity. And the patient won't be the one titrating their baclofen, etc.

and none of that will change my anesthetic for a cataract.

I mean I respect what the PMR docs do for these guys day to day, but they have literally zero idea how any of the patient's issues impact an anesthetic. It's just that they don't know what they don't know and we do. That's why I went to medical school and did a residency. I mean let's be honest, in the anesthesia grand scheme of how difficult this case is to manage it's about a 2 on a scale of 1-10. This isn't the achondroplastic dwarf having a liver transplant or the hemophiliac with critical AS that has free air in their abdomen.

 

[lobelsteve]

Lot of attitude here. If the guy has AD at home from leg being pinched, it is his fault. If he strokes out at 130/70 because of AD in your OR, it is your fault. Does it change your plan? No. Do we trust other docs to know that 120/80 is an urgency in this guy and look for a cause- not a chance.

 

[Planktonmd]

Lot of attitude here. If the guy has AD at home from leg being pinched, it is his fault. If he strokes out at 130/70 because of AD in your OR, it is your fault. Does it change your plan? No. Do we trust other docs to know that 120/80 is an urgency in this guy and look for a cause- not a chance.

When you say "WE don't trust other doctors" who are you referring to by "WE"? Is it YOU as a person but your greatness is beyond being addressed as singular? Or is it you and others like you who are so fu*king smart that you feel entitled to say stupid things like "Lot of attitude here"???

 

[Noyac]

Lobelsteve, in general we all appreciate any input from doctor to doctor. I also don't think that anyone here means to come off with attitude. The thing is that this is a 20 minute case with no stimulation. It will be over before we are done charting. Any issues can also be addressed since it isn't an emergency. It would take longer to get in touch with one of his Docs than it will to do the case. Sure If I saw him a couple days before surgery and I had questions then I would contract the treating physician but this is probably a case the nurse would clear for surgery. So the bottom line is that whatever information you would give me that would assist with the case, I could gain from the pt himself. Spasms, breathing, cough, AD, meds, ability to lye flat, problems with anesthesia, allergies, etc will either be on the chart or I can get from the pt. I would not touch the Baclofen because the case is so short. PNA I can assess. All those things cbest said I can either assess myself or they will not cause an issue in a 20 min case.
So it's not about giving attitude. It's about knowing how to handle these pts safely and moving on. I would guess that a PM&R doc has less knowledge of anesthesia than an anesthesiologist has of SCI pts. Just a guess but you get my point. I have placed IT baclofen pumps in these pts. Not every anesthesiologist has done this, I know. But the point is we treat these types of pts frequently. We don't send them off to the Mecca just because they have a SCI.
So all attitude aside, I appreciate the point you guys are making and enjoy the discourse but you guys should walk in our shoes as well some time. Nobody is trying to offend anyone.

 

[Planktonmd]

Lobelsteve, in general we all appreciate any input from doctor to doctor. I also don't think that anyone here means to come off with attitude. The thing is that this is a 20 minute case with no stimulation. It will be over before we are done charting. Any issues can also be addressed since it isn't an emergency. It would take longer to get in touch with one of his Docs than it will to do the case. Sure If I saw him a couple days before surgery and I had questions then I would contract the treating physician but this is probably a case the nurse would clear for surgery. So the bottom line is that whatever information you would give me that would assist with the case, I could gain from the pt himself. Spasms, breathing, cough, AD, meds, ability to lye flat, problems with anesthesia, allergies, etc will either be on the chart or I can get from the pt. I would not touch the Baclofen because the case is so short. PNA I can assess. All those things cbest said I can either assess myself or they will not cause an issue in a 20 min case.
So it's not about giving attitude. It's about knowing how to handle these pts safely and moving on. I would guess that a PM&R doc has less knowledge of anesthesia than an anesthesiologist has of SCI pts. Just a guess but you get my point. I have placed IT baclofen pumps in these pts. Not every anesthesiologist has done this, I know. But the point is we treat these types of pts frequently. We don't send them off to the Mecca just because they have a SCI.
So all attitude aside, I appreciate the point you guys are making and enjoy the discourse but you guys should walk in our shoes as well some time. Nobody is trying to offend anyone.

Man you are being too nice!

 

[Noyac]

Man you are being too nice!

You know me. I push the limits until I offend someone then I back off.
Just jokin around Lobelsteve. I've always enjoyed your input on this site. You bring a wealth of good knowledge to us all. And always very cordial. Happy Thanksgiving!

 

[pjl]

I think more the issue is that the PMR guys here are not aware how much of a non-issue cataract surgery is.


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[Planktonmd]

Just jokin around Lobelsteve. I've always enjoyed your input on this site. You bring a wealth of good knowledge to us all. And always very cordial.

 

[lobelsteve]

All good guys. My training was PMR. I only do pain. And I'm in the OR cutting on folks a bit. My experience is all on the other side of the curtain. I have a great Anes department and the MDs are always there to help out the AAs. But my cases are all so easy like the eye guys it is relaxing for the Anesthesiologists to get me. I don't operate on sick people.

 

[Mman]

Lot of attitude here. If the guy has AD at home from leg being pinched, it is his fault. If he strokes out at 130/70 because of AD in your OR, it is your fault. Does it change your plan? No. Do we trust other docs to know that 120/80 is an urgency in this guy and look for a cause- not a chance.

when it comes to acute blood pressure management, we are the experts. We are checking the BP every 60-180 seconds (unless we have an a-line which is then continual) which is way more frequently than anybody else watches the BP. We treat it on the order of seconds. We keep their BP close to their baseline, whatever their baseline is. We have quicker access to stronger BP meds to make it go up or down as needed than anywhere else in the hospital. If he gets wheeled in the door with a BP of 120/80, he won't stroke out at 130/70 (which is actually a lower MAP than 120/80). Cerebral autoregulation tends to work it out over that narrow of a range.

While I'm sure PMR docs are the expert in the chronic management of these patients, I'd be amazed if you guys are ever treating their BP every few seconds.

And it's a freakin cataract. Want to know the average anesthetic management of a cataract in this country? A valium and some eye drops. That's it. Anesthesiologists usually aren't even involved it's such a nothing. While the patient in this description might have a cervical injury, the innervation to his eye from his cranial nerves is unaffected by that injury.

 

[Psai]

Didn't know that (not that I'd have tried a dopamine infusion in this patient 😉).

Wonder if you'd get enough upstream flow from a lumbar drain ...

Might have to go transcranial and put the catheter in a ventricle.

Why waste time going transcranial and risking cerebral damage? First, do no hard.

Just put in a spinal and then place the patient upside down on a tilt table to really get the dopamine mixed into the csf. Our expert pm&anesthesiology doc up there can help with shaking the patient up. Should be easy enough as long as there's no tumor obstructing the 4th ventricle.