Call case

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
fakin' the funk

fakin' the funk

Full Member
Verified Member
15+ Year Member
Joined
Aug 23, 2004
Messages
2,934
Reaction score
983
Members don't see this ad.
65M with shoulder septic arthritis, ortho wants to do arthroscopic I+D/washout, says this is emergent because very high WBC count on aspirate means joint is at risk. Ortho will only do it under GA.

PMH: severe COPD, should be on oxygen but homeless; severe OSA, should be on CPAP but homeless; current smoker; morbid obesity (BMI = 45); DM; HTN. Admitted 10+ times in last year for COPD exacerbations, finished prednisone taper from most recent one 1 day ago. No anticoagulants, intermittent antihypertensive use.

VS wnl except RR = 22 and SpO2 = 95% on 2L NC. Exam: Santa beard, MP3, thick neck, edentulous, full head/neck ROM. Somnolent, dozes off in the middle of sentences. Wheezing you can hear from the doorway. Pitting edema to mid-shin. Labs wnl. Pt states his cough, sputum quality and quantity, and SOB are all at baseline. States he develops dyspnea "turning over in bed."

Your plan, doctor?
 
fakin' the funk said:
65M with shoulder septic arthritis, ortho wants to do arthroscopic I+D/washout, says this is emergent because very high WBC count on aspirate means joint is at risk. Ortho will only do it under GA.

PMH: severe COPD, should be on oxygen but homeless; severe OSA, should be on CPAP but homeless; current smoker; morbid obesity (BMI = 45); DM; HTN. Admitted 10+ times in last year for COPD exacerbations, finished prednisone taper from most recent one 1 day ago. No anticoagulants, intermittent antihypertensive use.

VS wnl except RR = 22 and SpO2 = 95% on 2L NC. Exam: Santa beard, MP3, thick neck, edentulous, full head/neck ROM. Somnolent, dozes off in the middle of sentences. Wheezing you can hear from the doorway. Pitting edema to mid-shin. Labs wnl. Pt states his cough, sputum quality and quantity, and SOB are all at baseline. States he develops dyspnea "turning over in bed."

Your plan, doctor?
Click to expand...

This is considered an emergent case as a septic joint can get destroyed in a matter of hours.

So you need to do something.

Options? GA vs Regional vs local.

Regional might not be your best option as you may knock out the diaprhagm/intercostals with an ISB which is tolerated by most, but maybe not this guy. Also, you have a site that is infected close to where your needle entry will be. So, for me, this is out.

General is my personal choice here. The question would be ETT or not. He's big, but he will be in the sitting position so I have no problems with an LMA IF you can get it to seal good enough to deliver good TV's (edentulous). You may have to shave off his beard OR put a large tegaderm with a hole in the middle of it so you can effectively mask ventilate if it becomes an issue.

ETT is always an option. So prop, sux tube is the immediate backup despite the fact that you should be in and out in a matter of 30 minutes. ETT from the get go is also a good safe plan.

If it's 2 ports, you may be able to get away with generous local and a good pre-op talk + back up plan. I&D shouldn't take long. I would choose this over ISB.

This case doesn't seem that difficut although his pitting edema and long h/o OSA might mean he has some right sided heart issues. Either way, it's an emergency, so you need to proceed.
 
Just shave his beard. Why make it difficult for yourself? It'll grow back in a few months, and being clean-shaven is much better than being hypoxic. He's already edentulous and obese, so that's two strikes against you. Why have a third?
 
Re: local for the case. Remember that local may not work that well in infected (acidic) tissue. So you absolutely need a back up plan.
 
Sitting position PreO2 5 min with mask strap, Propofol, Ketamine, Sux. Glidescope intubate standing on step--ask Ortho which ETT they want to do the case. Admit to unit post op.
 
With severe COPD s/p very recent exacerbation and steroid taper, post-op mechanical ventilation may be more of an immediate reality, and thus the concerns of the combination of OSA and GA are less of an issue. Still, I would argue that a single-shot suprascapular (field block vs U/S-guided) should provide very good analgesia, and allow some sparing of perioperative opiates, and minimize respiratory depression in this gentleman with both OSA and COPD (assuming he can separate from the vent at the end of the procedure, making this a relevant goal). This approach has the added benefit of not affecting the phrenic nerve. Since this patient has a somewhat poor airway, poor respiratory function, possible signs of right-sided ventricular dysfunction, and will be in the sitting position under drapes, with his airway not in my immediate vicinity, he is getting a tube. As such, I do not see a significant benefit in combining both supraclavicular or isolated axillary block with the suprascapular for total shoulder joint coverage.

His beard has got to go before we induce, as has already been mentioned. He sounds already partially induced (hypercarbia? sepsis? intoxication?), given his dozing mid-sentence. The horrendous wheezing and COPD hx suggest very limited pulmonary reserve. Have him sit up/ramp, preoxygenate, induce with propofol/sux (assuming normal-range blood pressure and potassium, with no hx of renal dysfunction), intubate with glidescope in that position.
 
Ketamine + Sux RSI induction after good Preoxygenation. Keep the Glidescope in the room just in case. ETT (don't like LMA in sitting position). NGT/OGT for sure. Stress dose of steroid. A-line for ABG's and glucose monitoring. Extubation trial at the end with possible CPAP, if the pt does not fly, keep him intubated in the ICU on Precedex until meds wear off and he is extubatable or CPAP-able.
 
gasp said:
Ketamine + Sux RSI induction after good Preoxygenation. Keep the Glidescope in the room just in case. ETT (don't like LMA in sitting position). NGT/OGT for sure. Stress dose of steroid. A-line for ABG's and glucose monitoring. Extubation trial at the end with possible CPAP, if the pt does not fly, keep him intubated in the ICU on Precedex until meds wear off and he is extubatable or CPAP-able.
Click to expand...

okay fine, why ketamine?
 
gasp said:
Ketamine + Sux RSI induction after good Preoxygenation. Keep the Glidescope in the room just in case. ETT (don't like LMA in sitting position). NGT/OGT for sure. Stress dose of steroid. A-line for ABG's and glucose monitoring. Extubation trial at the end with possible CPAP, if the pt does not fly, keep him intubated in the ICU on Precedex until meds wear off and he is extubatable or CPAP-able.
Click to expand...

This is the part that I don't do on a routine basis. If the guy is appropriately NPO, why would I place an NG or OG no matter what just because he's large and diabetic. That is like every other case over here... Full stomach is a different story.

Pulled this out of a patient not too long ago. But he had an emergent case with a full stomach, so I refused to induce until I emptied his stomach. Glad I did.

puke.jpg
 
Originally Posted by gasp
Ketamine + Sux RSI induction after good Preoxygenation. Keep the Glidescope in the room just in case. ETT (don't like LMA in sitting position). NGT/OGT for sure. Stress dose of steroid. A-line for ABG's and glucose monitoring. Extubation trial at the end with possible CPAP, if the pt does not fly, keep him intubated in the ICU on Precedex until meds wear off and he is extubatable or CPAP-able.
Click to expand...

This is the part that I don't do on a routine basis. If the guy is appropriately NPO, why would I place an NG or OG no matter what just because he's large and diabetic. That is like every other case over here... Full stomach is a different story.

Pulled this out of a patient not too long ago. But he had an emergent case with a full stomach, so I refused to induce until I emptied his stomach. Glad I did.

puke.jpg
Click to expand...

1. He's dozing off in the middle of sentences so I'm not going to rely on his word of npo status. Its an emergent case so he is probably not npo anyways.

2. Morbidly obese and most likely has uncontrolled DM and who knows for how long. Going to assume he has some delayed gastric emptying here.

3. Want to decrease my chances of aspiration as much as possible. He would not do well if he aspirated on top of his baseline lung function.

4. Ngt or Ogt takes about 20 secs and fairly harmless.

Sent from my SPH-D710 using SDN Mobile
 
Fair enough. Just playing devils advocate here, so don't take me the wrong way:

So you are going to place an awake NG before his shoulder scope even if he tells you he last ate 8 hours ago?

Not all NG's are easy to place and they do cause some trauma in some patients. Bloody AW on DL, nose bleeds, etc.

Should I place an NG in all my bad COPDr's that come for emergency cases?

DM doesn't necessarily mean gastroperesis.

I likely wouldn't here, but if you are worried, then you should. 😉
 
gasp said:
He has severe active wheezing as per the op. K has good bronchodilating properties.
Click to expand...

it isnt unreasonable, id be more likely to use it if you could prove bronchial asthma and not morbid obesity combined with cardiac wheezing. im concerned about ketamine in the patient who looks like they could be in heart failure, as even though there are inotropic effects 2/2 ketamine, it can also impair the ability of the acute or chronic failing heart to respond to catecholamines, potentially worsening underlying dysfunction. at the dose you will want to give to induce, it may really affect you.

id probably treat this guy like an ICU intubation with a collection of lidocaine/fentanyl/midaz and just enough propofol to get him to close his eyes while i push the sux. but i also anticipate him going to the unit intubated afterwards.
 
Fair enough. Just playing devils advocate here, so don't take me the wrong way:<br />
<br />
So you are going to place an awake NG before his shoulder scope even if he tells you he last ate 8 hours ago?<br />
<br />
Not all NG's are easy to place and they do cause some trauma in some patients. Bloody AW on DL, nose bleeds, etc. <br />
<br />
Should I place an NG in all my bad COPDr's that come for emergency cases?<br />
<br />
DM doesn't necessarily mean gastroperesis. <br />
<br />
I likely wouldn't here, but if you are worried, then you should. 😉
Click to expand...

No offence taken. I was just explaining my reasoning. I would place it after induction. DM doesn't necessarily mean gastroparesis, your right. But nothing necessarily means anything in anesthesia. There is no right or wrong, I was just saying what I would do.

Sent from my SPH-D710 using SDN Mobile
 
gasp said:
No offence taken. I was just explaining my reasoning. I would place it after induction. DM doesn't necessarily mean gastroparesis, your right. But nothing necessarily means anything in anesthesia. There is no right or wrong, I was just saying what I would do.

Sent from my SPH-D710 using SDN Mobile
Click to expand...

👍

Groovy.
 
Just realized that I never posted the "what we actually did" part for this case.

Nothing pulmonary to optimize for this guy since this steaming pile of respiratory function was at his baseline.

Ortho team refused local or regional...until the attending surgeon laid eyes on the patient. Our team discussed the above-mentioned pitfalls of interscalene and general. Surgeon agreed to local and dropped some sage words like "you can't make $hit shine." Aside from the downside of the phrenic block with ISB, this guy's neck was like a tree trunk and honestly without a regional expert on hand I think an ISB was merely wishful thinking.

So...sitting position, O2 by NC keeping SpO2 in mid-90s, generous dilute local w/ epi by surgeon, ketamine in 20mg aliquots and droperidol in 1mg aliquots, and lots of encouragement, got us to a arthroscopic I+D that concluded with a surgeon-to-surgeon fist bump and a clean joint.
 
fakin' the funk said:
Just realized that I never posted the "what we actually did" part for this case.

Nothing pulmonary to optimize for this guy since this steaming pile of respiratory function was at his baseline.

Ortho team refused local or regional...until the attending surgeon laid eyes on the patient. Our team discussed the above-mentioned pitfalls of interscalene and general. Surgeon agreed to local and dropped some sage words like "you can't make $hit shine." Aside from the downside of the phrenic block with ISB, this guy's neck was like a tree trunk and honestly without a regional expert on hand I think an ISB was merely wishful thinking.

So...sitting position, O2 by NC keeping SpO2 in mid-90s, generous dilute local w/ epi by surgeon, ketamine in 20mg aliquots and droperidol in 1mg aliquots, and lots of encouragement, got us to a arthroscopic I+D that concluded with a surgeon-to-surgeon fist bump and a clean joint.
Click to expand...

very slick. 👍
 
Oggg said:
Bleah ketamine droperidol sounds disgusting. Glad it worked out.
Click to expand...

Like our surprisingly-sage ortho friend said, you can't make $hit shine. This was a dirty case -- dirty shoulder, dirty patient, 3am at a shortstaffed VA -- and an admittedly dirty anesthetic doesn't seem so out of place.

I suppose I left out the history of schizophrenia and general VA-patient-mental-instability vibe I got from the guy when I wrote up the HPI.

I think the mental shortcut to "prop, sux, tube" or "prop, LMA" that some are advocating is incredibly shortsighted. So...if the dude gets trached because of inability to wean from vent that started with your general anesthetic, would everyone still stand by their decision to "take their chances" with prop/sux/tube and essentially turf the case to the ICU?
 
the anesthestic you described is worriesome a few reasons: yes it sounds like a nice idea to maintain spontaneous respiration, not mess with his already tenuous airway, and provide regional analgesia and some through ketamine without knocking out respirations.. so i get that... but some pretty obvious downsides, and BTW this guy potentially (unlikely given no home o2, no cpap) needing a trach is not your problem if he needs a tube to get safely through surgery.

downsides:
your giving ketamine to a psychotic guy

if you give too much fentanyl/midaz/ppfl to supplement your block hes your risking apnea and having to resort to intubating/lma emergently during surgery instead of a controlled induction - even more likely in the psychotic patient for him to get squirrely

you have a totally unprotected airway in a guy who likely has some GI motility issues and is receiving ketamine boluses and may have some respiratory issues after a little sedation, and is not communicative so could be aspirating on you throughout the case

how good is your local infiltration going to be on this fat guy? im surprised this worked actually..

anyways, i like your approach, but some would consider it high risk to quickly turn into a pain in the ass situation, so I would just preempt this by controlled induction (maybe even spont breathing with ketamine/midaz, low dose ppfl, or sevo) short acting if any relaxants, intubation to end all airway concerns (no teeth no problem, but GS backup). At that point it is beyond you what happens, the case will go fine now that it is more controlled, and post-operatively this guy will either fly immediately or need a little ICU TLC to finally get the tube out. I would keep him spontaneously breathing on PSV 3-8 no peep as soon as induction agents wear off. limit narcotics, probably run some low dose dex, increased sevo if there is a problem with movement during the case
 
fakin' the funk said:
Like our surprisingly-sage ortho friend said, you can't make $hit shine. This was a dirty case -- dirty shoulder, dirty patient, 3am at a shortstaffed VA -- and an admittedly dirty anesthetic doesn't seem so out of place.
Click to expand...

Can't argue with success. Love the fact that ortho was actually willing to step outside their usual "he's MOVING he needs more relaxant" comfort window and do a case under mostly local.


fakin' the funk said:
I think the mental shortcut to "prop, sux, tube" or "prop, LMA" that some are advocating is incredibly shortsighted. So...if the dude gets trached because of inability to wean from vent that started with your general anesthetic, would everyone still stand by their decision to "take their chances" with prop/sux/tube and essentially turf the case to the ICU?
Click to expand...

I think fears of not being able to wean patients like this from the vent after GA are way overblown. Yes this guy has bad lungs, COPD, just coming off a steroid taper (IOW he's at baseline where he lives, apparently on the street without supplemental O2).

However, you wouldn't be intubating him for respiratory failure, you'd be intubating him for an I&D. IMO there's little reason to think extubation would be exceptionally difficult after 20 minutes on the vent.
 
Prop sux tube. Or if npo then prop lma. This case isn't rocket science. why do people insist on complicating things.

I have never seen a patient with copd have trouble coming off the vent in any case remotely similar to this. Like others have said, he's being tubed for airway control not respiratory failure.
 
Surfer said:
Prop sux tube. Or if npo then prop lma. This case isn't rocket science. why do people insist on complicating things.

I have never seen a patient with copd have trouble coming off the vent in any case remotely similar to this. Like others have said, he's being tubed for airway control not respiratory failure.
Click to expand...

Exactly!
:naughty:
 
You must log in or register to reply here.

Similar threads

castafari
Cardiac call rates
Replies
28
Views
3K
caligas
C
D
Call situation
Replies
25
Views
2K
UscGhost
U
W
Case discussion: why acidosis?
Replies
46
Views
3K
narcotics999
N
C
Cash for call tax implications
Replies
16
Views
2K
Ronin786
Ronin786
M
Case logs
Replies
7
Views
2K
Ashers
Ashers
Top