Case for discussion

[GatorBait1548]

55f pmhx RA with documented c-spine instability, 1.5cm mouth opening, 60kg for total hip. History of frank reflux. No other major cv or pulm comirbidities. Plan?

Not like some of the crazy cases I've seen on here but some interesting discussion points...

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[PonyUp]

In my CA1 opinion-

If you want to go to sleep: Precedex and an awake nasal fiberoptic. You can topicalize or SLN block or spray transtracheally depending on the culture at your institution. I'm sure you can fit an ovassapian airway in a 1.5cm mouth opening if you had to, if you wanted an oral tube. Because in my mind frank reflux does not equal frank aspiration [in an awake patient], an AFOI seems reasonable and prevents you from having to extend their neck or open their mouth.

If you want to do the case under spinal, you'll get an extra level based on the hx of RA. If lateral I'd use hypobaric bupi. There's always the option of epidural as well.

Regardless of whether the patient is going to be sedated versus asleep I'd feel more comfortable if the known unstable c-spine was stabilized with whatever collar is appropriate, prior to entering the OR.

 

[OB1🤙]

Spinal, Sudoku.

 

[Ignatius J]

CSE, Precedex infusion.

 

[ZzzPlz]

Prop, sux, tube.

But seriously, she's either getting a spinal and isn't getting much sedation or she's getting an awake intubation. Her choice.

Oh and did I mention I would document???

 

[deleted171991]

Oral boards question: After 90 minutes of surgery, the patient starts complaining of pain...

 

[narcusprince]

Lol FFP should have AFOI the tube..... I would see where we are in the surgery. If closing skin I would inform the surgeons they need to speed up and close skin local/ketamine/fentanyl. If the surgeons are having difficulty placing the implants anterior approach the patient may be supine and in good position to topicalize AFOI with help in the room. If posterior approach this will be more difficult but inform the surgeons you need to secure the airway and position and AFOI. If you had an epidural in place just bolus that thing up and continue.

 

[OB1🤙]

If the airway is shady and the joint may be complicated- it's tetracaine +epi spinal time, folks!

 

[Mman]

Oral boards question: After 90 minutes of surgery, the patient starts complaining of pain...

dear surgeon this is a 30 minute case, why are we still here? The patient suggests you hurry up. Then give them some IV analgesia.

 

[Ignatius J]

Oral boards question: After 90 minutes of surgery, the patient starts complaining of pain...

Bolus epidural.

 

[Spinach Dip]

Oral boards question: After 90 minutes of surgery, the patient starts complaining of pain...

I've noted that intubation tends to decrease both the frequency and duration of patient complaints.

But seriously, she's either getting a spinal and isn't getting much sedation or she's getting an awake intubation. Her choice.

I'd assume a GA is incoming. IMO, you'd have to be a little crazy to elect for a spinal in a major surgery like a total hip (even with all the versed in the world). But I don't speak for everyone....


Anyway, this one is not as complicated as some I see here, so I'll give it a shot. Assuming GA:

1. Stabilize that c-spine. No reason to not do that first.
2. Awake FOI.
3. Sevo, surgery, and sudoku.
4. Wake her up. Take every (reasonable) precaution to be sure she doesn't reflux and aspirate.
5. Golf.

 

[Mman]

I'd assume a GA is incoming. IMO, you'd have to be a little crazy to elect for a spinal in a major surgery like a total hip (even with all the versed in the world). But I don't speak for everyone....

Wasn't there recently a large retrospective review suggesting lower morbidity/mortality periop for hips/knees under regional instead of GA? I'm way too lazy to look it up, but am fairly certain I read it in the last 12-18 months. There is certainly lower blood loss under spinal compared to GA, though the importance of that is debatable.

 

[OB1🤙]

I've done total hips with zero sedation, with headphones on the patient and an OR computer pulled over to the bedside with a Netflix movie on.

I'd rather do that than monkey with an unstable c-spine, but that's just me, and obviously requires a willing patient.

 

[narcusprince]

Assuming you do an AFOI intubation with cervical stabilization. I would like to know is the neck stable or unstable? And for the junior residents out there what determines neck stability? When most of you do AFOI in unstable necks do you check grip strength after the tube is in place as a mini-neuroexam? I had an attending in residency who would document grip strength after the AFOI in unstable necks then propofol and go to sleep.

 

[Spinach Dip]

And for the junior residents out there what determines neck stability?

I suppose one of these might help?

 

[caligas]

Wasn't there recently a large retrospective review suggesting lower morbidity/mortality periop for hips/knees under regional instead of GA? I'm way too lazy to look it up, but am fairly certain I read it in the last 12-18 months. There is certainly lower blood loss under spinal compared to GA, though the importance of that is debatable.

http://www.bmj.com/content/321/7275/1493

 

[narcusprince]

Spinach how do you classify a neck as stable versus unstable?

 

[deleted162650]

Nobody thinks maybe she outta have that documented unstable C-spine addressed/fused before proceeding with an elective total hip??

 

[caligas]

If the airway is shady and the joint may be complicated- it's tetracaine +epi spinal time, folks!

Or 15mg Isobaric bupiv w epi

 

[Spinach Dip]

Spinach how do you classify a neck as stable versus unstable?

Unfortunately that is beyond my expertise. My best suggestion at this time is to immobilize it well before proceeding with anything.

But if you have any wisdom to share, I'm all ears. (Er, eyes. This website is still visual...)

 

[Spinach Dip]

I've done total hips with zero sedation, with headphones on the patient and an OR computer pulled over to the bedside with a Netflix movie on.

 

[narcusprince]

I will let a resident or medical student answer before I chime in. I was asked this on my oral boards.....

 

[BLADEMDA]

Oral board answer is not my real world practice: I do a single shot SAB as I know every Otho surgeon quite well and will adjust drug dosage/type appropriately.

 

[BLADEMDA]

Wasn't there recently a large retrospective review suggesting lower morbidity/mortality periop for hips/knees under regional instead of GA? I'm way too lazy to look it up, but am fairly certain I read it in the last 12-18 months. There is certainly lower blood loss under spinal compared to GA, though the importance of that is debatable.

Anesthesiology. 2013 May;118(5):1046-58. doi: 10.1097/ALN.0b013e318286061d.
Perioperative comparative effectiveness of anesthetic technique in orthopedic patients.
Memtsoudis SG1, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE.
Author information

Abstract
BACKGROUND:
The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes.

METHODS:
Data from approximately 400 hospitals between 2006 and 2010 were accessed. Patients who underwent primary hip or knee arthroplasty were identified and subgrouped by anesthesia technique: general, neuraxial, and combined neuraxial-general. Demographics, postoperative complications, 30-day mortality, length of stay, and patient cost were analyzed and compared. Multivariable analyses were conducted to identify the independent impact of choice of anesthetic on outcomes.

RESULTS:
Of 528,495 entries of patients undergoing primary hip or knee arthroplasty, information on anesthesia type was available for 382,236 (71.4%) records. Eleven percent were performed under neuraxial, 14.2% under combined neuraxial-general, and 74.8% under general anesthesia. Average age and comorbidity burden differed modestly between groups. When neuraxial anesthesia was used, 30-day mortality was significantly lower (0.10, 0.10, and 0.18%; P < 0.001), as was the incidence of prolonged (>75th percentile) length of stay, increased cost, and in-hospital complications. In the multivariable regression, neuraxial anesthesia was associated with the most favorable complication risk profile. Thirty-day mortality remained significantly higher in the general compared with the neuraxial or neuraxial-general group for total knee arthroplasty (adjusted odds ratio [OR] of 1.83, 95% CI 1.08-3.1, P = 0.02; OR of 1.70, 95% CI 1.06-2.74, P = 0.02, respectively).

CONCLUSIONS:
The utilization of neuraxial versus general anesthesia for primary joint arthroplasty is associated with superior perioperative outcomes. More research is needed to study potential mechanisms for these findings.

 

[deleted171991]

Oral board answer is not my real world practice: I do a single shot SAB as I know every Otho surgeon quite well and will adjust drug dosage/type appropriately.

Bingo! That should be the right answer for the boards: a plan adjusted to both the patient AND the surgeon.

Assuming you do an AFOI intubation with cervical stabilization. I would like to know is the neck stable or unstable? And for the junior residents out there what determines neck stability? When most of you do AFOI in unstable necks do you check grip strength after the tube is in place as a mini-neuroexam? I had an attending in residency who would document grip strength after the AFOI in unstable necks then propofol and go to sleep.

That's OK for cervical spine surgery, but in this case it doesn't mean anything, since any cervical spinal cord issues are on you.

In my book, the best way to do this case is either neuraxial with an awake patient (Hawaiian Bruin-style), or AFOI GA (with a C-collar on, opened just during intubation) if the surgeon sucks. For the neuraxial version, I would even titrate some low-dose propofol, more for anxiolysis than sedation.

Nobody thinks maybe she outta have that documented unstable C-spine addressed/fused before proceeding with an elective total hip??

This is a very good question. Unfortunately, I don't know the answer, except that I would explain and document the hell out of it, during the informed consent process. If the patient wants her hip surgery first, despite severe warnings, I can't fix stupid.

 

[GatorBait1548]

Thanks for the discussion. I did the case under lumbar epidural (for intraop dosed with lido/Epi then ran ropiv infusion for post op pain until POD2). Awake positioning for c-spine was one big reason I preferred neuraxial approach. Ran very low propofol (20-30). Felt comfortable masking if need be (didn't have to) in lateral position and worst case FOI laterally. In hindsight a CSE would have been more of a sure thing but I made sure the epidural was surgical before proceeding to the OR.

If real, the netflix on the computer trumps all...

 

[OB1🤙]

The last time I did the Netflix thing was for a patient with severe bioprosthetic mitral stenosis, aortic stenosis, and resulting severe pulmonary hypertension. No cardiac surgeon would touch her for a redo double valve.

But she was living life in misery from hip OA, and found an orthopod willing to try. Pt and surgeon knew the operation could kill her but were willing to proceed to improve QOL.

I put in a spinal catheter, slowly dosed it with a cc at a time of 0.25% bupi, and did the Netflix thing. She said it was easier than going to the dentist. Case went great.

 

[narcusprince]

An unstable neck, is characterized by reproduction of nuerologic symptoms with normal range of motion. If a patient comes with a collar I usually remove the anterior portion of the collar if using glidescope if the neck is cleared, or AFOI with collar in place if not cleared. Clearing the neck requires these criterion to be met no evidence of intoxication, no distracting injury, patient is a alert and oriented x 3, no focal neurologic deficit, or no cervical midline tenderness. I know this sounds silly but how many of you have placed a spinal with a patient in a c-collar? If it was my patient AFOI and off to sleep. I agree why are we doing a elective case in a patient with an unstable neck?

 

[Ignatius J]

Thanks for the discussion. I did the case under lumbar epidural (for intraop dosed with lido/Epi then ran ropiv infusion for post op pain until POD2). Awake positioning for c-spine was one big reason I preferred neuraxial approach. Ran very low propofol (20-30). Felt comfortable masking if need be (didn't have to) in lateral position and worst case FOI laterally. In hindsight a CSE would have been more of a sure thing but I made sure the epidural was surgical before proceeding to the OR.

If real, the netflix on the computer trumps all...

Solid job, Gator. Have to disagree with you on a CSE being better. I hate after two hours the spinal wears off and you start bolusing up the epidural without ever having an idea about it's efficacy with the patient in an awkward position.

With unreliable surgeons, I'll take the extra 5-10min and dose up the epidural without doing a spinal.

 

[mdan]

An unstable neck, is characterized by reproduction of nuerologic symptoms with normal range of motion. If a patient comes with a collar I usually remove the anterior portion of the collar if using glidescope if the neck is cleared, or AFOI with collar in place if not cleared. Clearing the neck requires these criterion to be met no evidence of intoxication, no distracting injury, patient is a alert and oriented x 3, no focal neurologic deficit, or no cervical midline tenderness. I know this sounds silly but how many of you have placed a spinal with a patient in a c-collar? If it was my patient AFOI and off to sleep. I agree why are we doing a elective case in a patient with an unstable neck?

But what about for a RA c-spine that has AA subluxation considered unstable in flexed position on XR? Patient otherwise walks around with without a collar and has no symptoms when awake through the normal ROM. Awake fibre optic and confirm grossly normal motor exam post intubation before off to sleep? C-collar on after intubation and for duration of procedure?

 

[Psai]

I would avoid flexing the neck

 

[dhb]

In residency i trained at one place where a spinal with no sedation (maybe 1cc or2 of midaz) was to go to anesthetic for hip surgery It's fine for 1.5h after that patient starts being uncomfortable.

 

[Hoya11]

55f pmhx RA with documented c-spine instability, 1.5cm mouth opening, 60kg for total hip. History of frank reflux. No other major cv or pulm comirbidities. Plan?

Not like some of the crazy cases I've seen on here but some interesting discussion points...

Does she come in with a collar on? Or is she leading her normal life, cooking, driving, and doing activities without any issues with her neck...How long has it been "unstable" without any required intervention? C spine "instability" is a spectrum, from someone who needs a collar and can have major compromise from slight manipulation (very rare) to "instability" that was only documented on lawyer requested advanced "flex/ex" xrays showing some "ligamentous" instablity in certain positions/motions. This is more or less a normal person with just some neck pain and unless you strangle/try to decapitate them they will be OK just like a normal neck.. there are lots of these people and its more of a legal/workmans comp/fibromyalgia type of "instability". No collar on? Prove to me that its really unstable and you are just not making some claim off of vague pain symptoms and a random imaging finding..

I would imagine she had no collar on, was on chronic pain medications, and had not had any intervention to her "unstable" neck due to no surgeon thinking it was significant enough to operate on

 

[Mman]

In residency i trained at one place where a spinal with no sedation (maybe 1cc or2 of midaz) was to go to anesthetic for hip surgery It's fine for 1.5h after that patient starts being uncomfortable.

does anybody ask the patients if they'd like to listen to the sound of the surgeon jackhammering their femur? Or the sensation of the bed shaking when they are doing so?

We do plenty of regional on joint patients, but it is less than 1/100 I take care of that want to be aware and remember during the procedure.

 

[dhb]

does anybody ask the patients if they'd like to listen to the sound of the surgeon jackhammering their femur? Or the sensation of the bed shaking when they are doing so?

We do plenty of regional on joint patients, but it is less than 1/100 I take care of that want to be aware and remember during the procedure.

Headphones & video vs GA

 

[Mman]

Headphones & video vs GA

just time out the parts of the movie to the hammering on the joint for extra special effects

 

[dhb]

just time out the parts of the movie to the hammering on the joint for extra special effects

4D surgery is a good selling point when you renogociate the contract.
#7figures