Case Today

[Hork Bajir]

73 yo guy scheduled for CT-guided lung biopsy of a large LUL mass with IR. He has really bad IPF, baseline SpO2 80-88% on 10L NC at rest. Desats into the 70s with speaking full sentences, and into the 60s with pretty much any activity. Can lay flat for short periods, but doesn't love it. Needs the biopsy done b/c if it turns out to be a ball of scar tissue and not cancer, he could likely be listed for lung transplant.

On top of that has severe pulmonary HTN (PASP 88 on recent RHC), RV dilated and diffusely hypokinetic, severe TR. Diffuse coronary disease on LHC, though no known ischemia (likely because his functional status is 0).

In pre-op bay he's EXTREMELY anxious. For the case he needs to go prone, with head away from the anesthesia machine. IR guy says it'll take about an hour once they get underway.

Go...

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[Psai]

Coronary disease doesnt bother me because nejm 2004 says fixing it won't help. High flow nasal cannula at 80%/30L. tiny amount of precedex maybe 0.2 or so. Serratus anterior block with bupi 0.25% 20 cc. Big femoral central line. Big ij central line. Heparinize. Vv ecmo. When procedure is over, decannulate. To the icu.

 

[anbuitachi]

give him some low dose midaz and be done with it, and why does this case take 1 hr?!

 

[GravelRider]

Local and some anxiolysis.

What’s his code status? Ensure that he has good insight into how close he is to death every second of the day.

 

[jwk]

give him some low dose midaz and be done with it, and why does this case take 1 hr?!

Agree - this can be done in 10 min at our place as long as everyone is in place and ready to go.

 

[deleted162650]

This guy is gonna do great with the inevitable post procedure pneumo.

 

[UrbanAchievers]

Highly doubt this patient would ever be listed for a lung transplant.

 

[deleted59964]

I’d use hfnp, and titrate alfentanil, and if necessary tiny doses of propofol.

I’m also surprised this guy is even remotely a lung transplant candidate.

A question for the cardiac folks - will his PHTN resolve after lung transplant?

 

[Radetzky]

I’d use hfnp, and titrate alfentanil, and if necessary tiny doses of propofol.

I’m also surprised this guy is even remotely a lung transplant candidate.

A question for the cardiac folks - will his PHTN resolve after lung transplant?

Yes, assuming you transplant both lungs

 

[coffeebythelake]

A question for the cardiac folks - will his PHTN resolve after lung transplant?

RV dilated and diffusely hypokinetic
he won't get a lung transplant unless they also plan to replace his heart

 

[Hoya11]

73 yo guy scheduled for CT-guided lung biopsy of a large LUL mass with IR. He has really bad IPF, baseline SpO2 80-88% on 10L NC at rest. Desats into the 70s with speaking full sentences, and into the 60s with pretty much any activity. Can lay flat for short periods, but doesn't love it. Needs the biopsy done b/c if it turns out to be a ball of scar tissue and not cancer, he could likely be listed for lung transplant.

On top of that has severe pulmonary HTN (PASP 88 on recent RHC), RV dilated and diffusely hypokinetic, severe TR. Diffuse coronary disease on LHC, though no known ischemia (likely because his functional status is 0).

In pre-op bay he's EXTREMELY anxious. For the case he needs to go prone, with head away from the anesthesia machine. IR guy says it'll take about an hour once they get underway.

Go...

You dont have a choice but to intubate him given hes under the CT machine and far away, is prone, and has high oxygen requirements.

Your likely going to be monitoring this case from outside the room keep in mind.

So you intubate, paralyze, and plan to keep intubated in the ICU after.

Probably a neo drip. I think 2 peripheral IVs are fine.

Hopefully they can extubate him with lots of time in the ICU after the procedure.

 

[AdmiralChz]

RV dilated and diffusely hypokinetic
he won't get a lung transplant unless they also plan to replace his heart

Plus he’s 73. I don’t know if many centers that would seriously consider transplant - his mortality risk is sky-high and in an age where 12 month mortality really matters... Plus the comorbid conditions look like they necessitate pulmonary endarterectomy (NO THANKS!) or combined heart-lung transplant, and he is just too old and too deconditoned for that.

Back to the case, it’s not going to be great. Others have had good ideas - I’d try to keep spontaneous for sure, hopefully this is a quick poke and leave.

10 L via NC all the time... I’m not sure that’s really possible or wise.

My plan: palliative care consult.

 

[AdmiralChz]

You dont have a choice but to intubate him given hes under the CT machine and far away, is prone, and has high oxygen requirements.

Your likely going to be monitoring this case from outside the room keep in mind.

So you intubate, paralyze, and plan to keep intubated in the ICU after.

Probably a neo drip. I think 2 peripheral IVs are fine.

Hopefully they can extubate him with lots of time in the ICU after the procedure.

I’d be pretty worried about his ability to get off the ventilator with this strategy.

 

[nimbus]

He’s extremely anxious because he’s going to die soon. I’d be anxious too.

He needs a goal of care meeting. Not a terminal biopsy. If he wanted the full court press, he should have been intubated 6 months ago.

 

[kidthor]

Wow - if anything I'd give a splash of midazolam... and that's it.

 

[teacher2md]

Just a junior resident; but here's my thoughts:

With this guy already hypoxemic, I would not take a chance of further hypoxemia/hypercarbia with any amount of sedation, especially in the prone position. Seeing that he's already anxious, it would probably require more than just a splash of midazolam. I'd be worried about his already-compromised RV with said hypercarbia.

Slow induction with etomidate/epinephrine; intubate; hide all of the phenylephrine in the room; use vasopressin if needed. Hope for post-op extubation, but plan for likely ICU admission afterward.

 

[deleted875186]

Slow induction with etomidate/epinephrine; intubate; hide all of the phenylephrine in the room; use vasopressin if needed. Hope for post-op extubation, but plan for likely ICU admission afterward.

I know the textbook says vasopressin won’t increase PA pressures. But will using phenylephrine or norepi really increase PA pressure significantly. The PA pressures will proabably come down after induction of anesthesia and correction of hypercarbia anyway.

 

[anbuitachi]

Just a junior resident; but here's my thoughts:

With this guy already hypoxemic, I would not take a chance of further hypoxemia/hypercarbia with any amount of sedation, especially in the prone position. Seeing that he's already anxious, it would probably require more than just a splash of midazolam. I'd be worried about his already-compromised RV with said hypercarbia.

Slow induction with etomidate/epinephrine; intubate; hide all of the phenylephrine in the room; use vasopressin if needed. Hope for post-op extubation, but plan for likely ICU admission afterward.

whats your access going to be? what infusions?

 

[GravelRider]

Oxygenation often improves in the prone position. It might not in this guy, but the prone position should not really be too much of a factor if you are planning minimal sedation.

Intubating this guy is a terminal event. You will never get him off the ventilator. Ultimately, he is going to die soon and should be well aware of that. Even if there is some magical plan to transplant his entire chest, palliative care should be involved.

 

[anbuitachi]

Oxygenation often improves in the prone position. It might not in this guy, but the prone position should not really be too much of a factor if you are planning minimal sedation.

Intubating this guy is a terminal event. You will never get him off the ventilator. Ultimately, he is going to die soon and should be well aware of that. Even if there is some magical plan to transplant his entire chest, palliative care should be involved.

agree w this. prone position sedation is great

And this is why it is so important for us to be able to do head/brain transplants in the future. transplant the head to a healthy brain dead body would help a lot of people

 

[deleted763299]

Resident here. I'll assume the patient wants to proceed after having an effective goals-of-care discussion (including palliative care), including the fact that any form of sedation is dangerous for him, and that a general anesthetic would likely be fatal. Here's my plan.

Tell the patient and the IR person he's not going to be asleep for this, period. I'm not an executioner, the patient needs to put his big boy pants on. The target level of sedation is minimal sedation. The IR person will have to use local effectively because this patient is not getting any opioid from me, hard stop. Arrange for high flow nasal cannula with Flolan for him, FiO2 100%. Awake art line, and 2 good PIV's. Baseline ABG prior to HFNC/Flolan initiation to establish your PaO2 target. If you can't get good PIV's, then an awake central line. He gets judiciously titrated precedex (no loading dose), plus or minus a tiny amount of midaz. Have a rack of drips (epi, norepi, vaso) ready in the not unlikely event that he decompensates.

 

[teacher2md]

Oxygenation often improves in the prone position. It might not in this guy, but the prone position should not really be too much of a factor if you are planning minimal sedation.

Intubating this guy is a terminal event. You will never get him off the ventilator. Ultimately, he is going to die soon and should be well aware of that. Even if there is some magical plan to transplant his entire chest, palliative care should be involved.

My concern with prone positioning isn't the physiology per se, but that the guy will become even more anxious and start squirming 5 minutes in, requiring increasing doses of sedatives. What if the procedure takes longer; say 2 hours? Would you still consider sedation? I'm worried about riding the thin line between anxious/squirming and sedated/hypoventilated.

If you chose to do sedation only, would you consider using ketamine or dexmetedomidine?

I agree that a frank discussion would be had regarding the high risk of morbidity/mortality.

 

[Noyac]

Good case OP.
A few of my thoughts:
1. He needs sedation now bc his anxiety is possibly making his PHTN worse. But be aware of hypoventilation.
2. He won’t tolerate a PTX very well. I’d prefer spontaneous ventilation of some sort in order to minimize positive pressure of a ventilator which will hasten his ultimate demise.
3. I wouldn’t bother with a block like someone mentioned. It’s only a needle and the IR guy can use local.
4. I’d probably have a chat with the pt and family stating that intubation was not in my plan at all. If we can’t get it done with sedation then we don’t do it.
5. Therefore ICU unnecessary.
6. Therefore vasopressin and neo unnecessary.
7. But then what do you do if the PTX really happens and he crumps? Do you honor the DNR? Do you intubate and see what happens? This is up to the pt and family. I’d steer them aware from this.
8. Call hospital Risk management before proceeding.
This is a case of first do no harm to me. I’d make all situations extremely clear to all participants.

 

[deleted171991]

One more idea to add to @Noyac's plan: precedex (or ketamine). Definitely not a GETA case.

This is a case of properly setting and managing expectations, both for the patient and the proceduralist.

 

[GravelRider]

I think this case is a good illustration of how your thinking evolves as you proceed in your career. This is where experience is different than the textbooks. Some of the posters self-identified as residents see the severity of the illness and want to throw the whole cookbook at this patient. We can use all the tools at our disposal (lines, drips, intubation, etc...), but that doesn’t mean we should. The absolute first thing I thought of when I see this patient is “less is more.” The work involved here is all the upfront preparation of expectations of all parties involved. You tell the IR guy this is going to be the fastest biopsy he’s ever performed because this patient is going to be awake and he’s super sick. You tell the patient that he is going to be awake, but you’ll be there to get him through it. You also re-emphasize the severity of his disease to him and his family. This case is more about “doctoring” and less about “anesthesia-ing.”

 

[Hork Bajir]

The absolute first thing I thought of when I see this patient is “less is more.” The work involved here is all the upfront preparation of expectations of all parties involved. You tell the IR guy this is going to be the fastest biopsy he’s ever performed because this patient is going to be awake and he’s super sick. You tell the patient that he is going to be awake, but you’ll be there to get him through it. You also re-emphasize the severity of his disease to him and his family. This case is more about “doctoring” and less about “anesthesia-ing.”

Agree with this 100%, though great discussion all around. Here's what we did:
- Frank discussion with patient, family, and proceduralist re-iterating the risks involved with proceeding, setting the expectation of VERY minimal sedation, and making clear that if the patient gets a pneumothorax or hemoptysis, he's very likely going to die today no matter what we do
- Access was 20g PIV placed by nurse in pre-op (he had the veins of someone in R heart failure, so if we needed to put in additional peripheral access it could have been done quickly and easily)
- While positioning prone on the table, patient desats to 50s... takes several minutes to recover. During this time patient is approximately the color of an eggplant
- Start HFNC 100% 50L/min, SpO2 improves to 100%
- Titrate in precedex 4mcg at a time, end up giving 24mcg total over about 30 minutes
- Patient slept through most of the procedure- interestingly, I think the biggest factor in treating his anxiety was the HFNC... amazing how anxious hypoxemia and increased work of breathing can make you

With respect to some of the points raised above:
- Had a stick of dilute epi on standby to ward of evil spirits, but figured if we needed to use it then it was probably game over anyway
- The process of placing a central line or a block in this dude would have been just as difficult and uncomfortable as doing the biopsy itself, and would have added some unnecessary time to the whole affair
- Per a discussion with CT surg, this guy actually could have been listed for a double lung transplant if the mass was not cancer. They said there's a reasonable chance the RV would recover if the lungs were transplanted. Not sure how likely it is that he would have actually gotten a pair of lungs once he got listed though... maybe with extended donor criteria

 

[Noyac]

What did the bx show?

 

[coffeebythelake]

you could kill this guy just intubating him, switching to positive pressure ventilation

 

[Psai]

Man I was just joking guys

 

[AdmiralChz]

Remind me not to be on call when this dude comes in for his double lung transplant. He’ll 100% be leaving the room on VA ECMO.

 

[Robotic Wis-Hipple]

Remind me not to be on call when this dude comes in for his double lung transplant. He’ll 100% be leaving the room on VA ECMO.

The residents here are getting a bad rap imo.

There are two ways to do this case, almost nothing or full court press. They both have pros and cons, the less is more strategy the guy could die and in the full court press strategy the guy ends up on the vent forever and you have to trach/peg him next week.

In an academic center this case is getting done, the guy likely is there on his 2nd or 3rd opinion after another center said no way for listing. So residents are used to going forward and doing it the safest way possible whereas guys out in the real world can take Noyac’s approach (which is perfect btw).

My point is a resident isn’t thinking about or doing cases where it’s reasonable to expect you’re going to let a patient expire in the OR as “the plan” if he decompensates during your less is more approach. What actually happens there is you tube him, and maybe he ends up on VA which puts him higher on the transplant list......

 

[Ronin786]

Remind me not to be on call when this dude comes in for his double lung transplant. He’ll 100% be leaving the room on VA ECMO.

Yup. I've seen this game play out before. RV failure with pHTN, everybody thinks getting rid of the after load is going to take care of it. Patient does absolutely terrible post-op, at best spends a couple weeks at death's door with VA ECMO. This guy still isn't in shock due to his RV failure so maybe there's a chance his heart recovers, but I'll never understand how given the scarcity of donors we're messing around with absolutely marginal recipients.

 

[Ronin786]

The residents here are getting a bad rap imo.

There are two ways to do this case, almost nothing or full court press. They both have pros and cons, the less is more strategy the guy could die and in the full court press strategy the guy ends up on the vent forever and you have to trach/peg him next week.

In an academic center this case is getting done, the guy likely is there on his 2nd or 3rd opinion after another center said no way for listing. So residents are used to going forward and doing it the safest way possible whereas guys out in the real world can take Noyac’s approach (which is perfect btw).

My point is a resident isn’t thinking about or doing cases where it’s reasonable to expect you’re going to let a patient expire in the OR as “the plan” if he decompensates during your less is more approach. What actually happens there is you tube him, and maybe he ends up on VA which puts him higher on the transplant list......

VA ECMO puts you at status 1 for heart transplants, but I don't think it's factored into lungs. Instead UNOS uses a formula that Einstein probably couldn't solve. No joke:

 

[Noyac]

The residents here are getting a bad rap imo.

There are two ways to do this case, almost nothing or full court press. They both have pros and cons, the less is more strategy the guy could die and in the full court press strategy the guy ends up on the vent forever and you have to trach/peg him next week.

In an academic center this case is getting done, the guy likely is there on his 2nd or 3rd opinion after another center said no way for listing. So residents are used to going forward and doing it the safest way possible whereas guys out in the real world can take Noyac’s approach (which is perfect btw).

My point is a resident isn’t thinking about or doing cases where it’s reasonable to expect you’re going to let a patient expire in the OR as “the plan” if he decompensates during your less is more approach. What actually happens there is you tube him, and maybe he ends up on VA which puts him higher on the transplant list......

This all reminds me of the saying, “you first must learn how to do Anesthesia in order to know when not too.”

I have no issues with an academic center taking a stab at this case with the full court press. How else are residents going to learn to do these cases?

 

[Noyac]

Yup. I've seen this game play out before. RV failure with pHTN, everybody thinks getting rid of the after load is going to take care of it. Patient does absolutely terrible post-op, at best spends a couple weeks at death's door with VA ECMO.

I sure hope everyone doesn’t think afterload reduction is the answer here. Unless you are talking about RV afterload only. Which is probably fixed (unchangeable).

 

[hankbb02]

Oxygenation often improves in the prone position. It might not in this guy, but the prone position should not really be too much of a factor if you are planning minimal sedation.

Intubating this guy is a terminal event. You will never get him off the ventilator. Ultimately, he is going to die soon and should be well aware of that. Even if there is some magical plan to transplant his entire chest, palliative care should be involved.

Leaving intubated also lowers his status on the transplant list.

 

[hankbb02]

I know the textbook says vasopressin won’t increase PA pressures. But will using phenylephrine or norepi really increase PA pressure significantly. The PA pressures will proabably come down after induction of anesthesia and correction of hypercarbia anyway.

Yes it does. Just watch it next time you have a PA catheter.

 

[dannyboy1]

The best Anestheia is no Anestheia. Where I am IR is extremely needy and they will call us for everything. A few times I made the point of hooking up the propofol pump and not even turning it on. Cases went just fine.

 

[hankbb02]

Agree with this 100%, though great discussion all around. Here's what we did:
- Frank discussion with patient, family, and proceduralist re-iterating the risks involved with proceeding, setting the expectation of VERY minimal sedation, and making clear that if the patient gets a pneumothorax or hemoptysis, he's very likely going to die today no matter what we do
- Access was 20g PIV placed by nurse in pre-op (he had the veins of someone in R heart failure, so if we needed to put in additional peripheral access it could have been done quickly and easily)
- While positioning prone on the table, patient desats to 50s... takes several minutes to recover. During this time patient is approximately the color of an eggplant
- Start HFNC 100% 50L/min, SpO2 improves to 100%
- Titrate in precedex 4mcg at a time, end up giving 24mcg total over about 30 minutes
- Patient slept through most of the procedure- interestingly, I think the biggest factor in treating his anxiety was the HFNC... amazing how anxious hypoxemia and increased work of breathing can make you

With respect to some of the points raised above:
- Had a stick of dilute epi on standby to ward of evil spirits, but figured if we needed to use it then it was probably game over anyway
- The process of placing a central line or a block in this dude would have been just as difficult and uncomfortable as doing the biopsy itself, and would have added some unnecessary time to the whole affair
- Per a discussion with CT surg, this guy actually could have been listed for a double lung transplant if the mass was not cancer. They said there's a reasonable chance the RV would recover if the lungs were transplanted. Not sure how likely it is that he would have actually gotten a pair of lungs once he got listed though... maybe with extended donor criteria

Interesting case. The RV will see a lot less afterload with new lungs provided that the transplanted lungs do not have pulm HTN (usually don't). The RV in this case is already strong considering the pressure it can generate.

Do you guys have VV ECMO capabilities at your hospital? If things did go poorly and he was placed on a transplant list it would be better to place him on ECMO than leave him intubated.

-Hank

 

[Ronin786]

I sure hope everyone doesn’t think afterload reduction is the answer here. Unless you are talking about RV afterload only. Which is probably fixed (unchangeable).

Interesting case. The RV will see a lot less afterload with new lungs provided that the transplanted lungs do not have pulm HTN (usually don't). The RV in this case is already strong considering the pressure it can generate.

Do you guys have VV ECMO capabilities at your hospital? If things did go poorly and he was placed on a transplant list it would be better to place him on ECMO than leave him intubated.

-Hank

I was talking about RV afterload in the context of a lung transplant. Based off this patient's echo, his RV is already shot. It's diffusely hypokinetic and dilated with diffuse CAD on cath. This patient is a disaster lung transplant. IPF diagnosis means it's going to be a long and bloody pump run. The RV will inevitably take another hit during the transplant and it's going to be a disaster trying to come off pump. This patient might survive, but the odds are definitely not in their favor.

 

[UrbanAchievers]

Couple of points:

No matter what pressor you use your PAs are going to increase when you raise the patients blood pressure. Vasopressin is usually preferred choice.

Lung transplants are already fraught with bad outcomes. Placing lungs in a patient like this is not going to help anyone’s 30 day or 1 year survival rates. If our transplant team brought in this patient for transplant, the expectations would be leaving on ECMO and probably serial washouts. Fortunately, our surgeons are fairly reasonable.

 

[deleted950463]

73 yo guy scheduled for CT-guided lung biopsy of a large LUL mass with IR. He has really bad IPF, baseline SpO2 80-88% on 10L NC at rest. Desats into the 70s with speaking full sentences, and into the 60s with pretty much any activity. Can lay flat for short periods, but doesn't love it. Needs the biopsy done b/c if it turns out to be a ball of scar tissue and not cancer, he could likely be listed for lung transplant.

On top of that has severe pulmonary HTN (PASP 88 on recent RHC), RV dilated and diffusely hypokinetic, severe TR. Diffuse coronary disease on LHC, though no known ischemia (likely because his functional status is 0).

In pre-op bay he's EXTREMELY anxious. For the case he needs to go prone, with head away from the anesthesia machine. IR guy says it'll take about an hour once they get underway.

Go...

Haven’t read any post above besides the OP, but a lung bx should not take an hour in experienced hands. If pt is getting intubated, he is actually somewhat protected against the more potentially catastrophic complication of hemorrhage. Post procedural pneumothroax is actually not a big deal here because you can always place a small caliber pigtail chest prophylactically. There are also options include gelfoam pledget and the biosentry device.

More over, if he’s intubated and can be made apnea, the procedure can be really really quick and easy. Much of the difficulty in CT guided lung bx comes from respiratory motion.

The argument for no intubation is that if the pt can tolerate it, most lung bx can actually be done without sedation or even just a bit of fentanyl and versed (like the ole 1 and 50).

If I were the operator in this case (fingers crossed for matching into IR 7 years down the line), I would ask the anesthesia service to try to hit him with a small amount of sedation, and try to bang it out quick. If he absolutely cannot tolerate it, then bring him back another day with intubation.

 

[DM27]

Regarding phenylephrine/norepi/vaso and PA pressures. I am at a center that uses an inappropriate amount of PA catheters and this is something I always pay attention to simply because it was something I was always curious about from textbooks. I can tell to you anecdotally that all 3 will raise PA pressure due to the increase in systemic pressure as stated above, and my experience with all 3 is that the ratio of PA/Systemic pressure with each agent never increased. So I would be hard pressed to say I agree with the statement that any of the agents selectively spare or worsen pulmonary vasoconstriction on any clinically relevant level.

 

[chocomorsel]

Man I was just joking guys

I know!! And I was laughing. That crap with the ECMO was awesome!!! And then decannulate at end of case was even better!!!

 

[deleted697535]

This guys gonna get 2 lungs and a heart? You're joking right??

He's not fit for a haircut...
Ye mad lunatics

 

[anbuitachi]

Agree with this 100%, though great discussion all around. Here's what we did:
- Frank discussion with patient, family, and proceduralist re-iterating the risks involved with proceeding, setting the expectation of VERY minimal sedation, and making clear that if the patient gets a pneumothorax or hemoptysis, he's very likely going to die today no matter what we do
- Access was 20g PIV placed by nurse in pre-op (he had the veins of someone in R heart failure, so if we needed to put in additional peripheral access it could have been done quickly and easily)
- While positioning prone on the table, patient desats to 50s... takes several minutes to recover. During this time patient is approximately the color of an eggplant
- Start HFNC 100% 50L/min, SpO2 improves to 100%
- Titrate in precedex 4mcg at a time, end up giving 24mcg total over about 30 minutes
- Patient slept through most of the procedure- interestingly, I think the biggest factor in treating his anxiety was the HFNC... amazing how anxious hypoxemia and increased work of breathing can make you

With respect to some of the points raised above:
- Had a stick of dilute epi on standby to ward of evil spirits, but figured if we needed to use it then it was probably game over anyway
- The process of placing a central line or a block in this dude would have been just as difficult and uncomfortable as doing the biopsy itself, and would have added some unnecessary time to the whole affair
- Per a discussion with CT surg, this guy actually could have been listed for a double lung transplant if the mass was not cancer. They said there's a reasonable chance the RV would recover if the lungs were transplanted. Not sure how likely it is that he would have actually gotten a pair of lungs once he got listed though... maybe with extended donor criteria

Why didn't you just start the HFNC before the positioning??

 

[chocomorsel]

Why didn't you just start the HFNC before the positioning??

I bet they did. It’s just that the whole 1 MET he took to transfer from stretcher to IR table got him severely winded.

 

[OB1🤙]

Prop sux tube en bloc heart double lung transplant next case

 

[Planktonmd]

Coronary disease doesnt bother me because nejm 2004 says fixing it won't help. High flow nasal cannula at 80%/30L. tiny amount of precedex maybe 0.2 or so. Serratus anterior block with bupi 0.25% 20 cc. Big femoral central line. Big ij central line. Heparinize. Vv ecmo. When procedure is over, decannulate. To the icu.

 

[Planktonmd]

Midazolam 1-2 mg... and tell them they need to do good local anesthesia!