Case today

[aphistis]

I'm curious about how other people's ideas line up with my own thoughts and how things actually went down.

It's noon and you've just finished your last scheduled case in one of the ortho rooms, and the charge nurse (politely, to her credit) interrupts your lunch to tell you they want to add a septic ankle washout immediately. Surgeon says it's an emergency that "really shouldn't wait a full eight hours. Her white count is 80, she's got pus, and it's destroying her cartilage."

The patient: 47yowf, DM, mild-mod COPD, active smoker/drinker/IVDA (maybe a dozen healing track marks on each wrist), admitted 7d ago for atraumatic R hand and ankle pain (the hand has since been identified as the result of a heroin injection into the dorsum). Cultures came back MRSA three days ago. No other known health issues. Her only meds are sliding scale insulin, PCA Dilaudid and abx. She ate a lumberjack breakfast at 0830.

The nurse is waiting patiently for your answer, and you tell her...?

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[Jeff05]

surgeon documents that this is a surgical emergency.
RSI.
extubate when awake.

I'm curious about how other people's ideas line up with my own thoughts and how things actually went down.

It's noon and you've just finished your last scheduled case in one of the ortho rooms, and the charge nurse (politely, to her credit) interrupts your lunch to tell you they want to add a septic ankle washout immediately. Surgeon says it's an emergency that "really shouldn't wait a full eight hours. Her white count is 80, she's got pus, and it's destroying her cartilage."

The patient: 47yowf, DM, mild-mod COPD, active smoker/drinker/IVDA (maybe a dozen healing track marks on each wrist), admitted 7d ago for atraumatic R hand and ankle pain (the hand has since been identified as the result of a heroin injection into the dorsum). Cultures came back MRSA three days ago. No other known health issues. Her only meds are sliding scale insulin, PCA Dilaudid and abx. She ate a lumberjack breakfast at 0830.

The nurse is waiting patiently for your answer, and you tell her...?

 

[dfk]

hyperbaric spinal, sit 'em up and give 'em an iphone to watch a video.

 

[bullard]

hyperbaric spinal, sit 'em up and give 'em an iphone to watch a video.

Sepsis is a relative contraindication to neuraxial anesthesia. RSI.

 

[ssmallz]

surgeon documents that this is a surgical emergency.
Rsi.
Extubate when awake.

+1

 

[Jeff05]

Regional Anesthesia and Pain Medicine, Vol 31, No 4 (July–August), 2006: pp 324 –333

Taken from:

Regional Anesthesia in the Febrile or Infected Patient

Recommendations
Recommendations are as follows:
1. Serious central neuraxial infections such as
arachnoiditis, meningitis, and abscess after spi-
nal or epidural anesthesia are rare (Grade B).
2. The decision to perform a regional anesthetic
technique must be made on an individual ba-
sis considering the anesthetic alternatives, the
benefits of regional anesthesia, and the risk of
local or systemic infection should be considered at
risk for developing infection of the CNS.
The clinical course of epidural abscess progresses
CNS infection (which may theoretically occur
in any bacteremic patient) (Grade C).
3. Despite conflicting results, many experts sug-
gest that, except in the most extraordinary
circumstances, central neuronal block should
not be performed in patients with untreated
systemic infection (Grade C).
4. Available data suggest that patients with evi-
dence of systemic infection may safely un-
dergo spinal anesthesia, provided appropriate
antibiotic therapy is initiated before dural
puncture and the patient has shown a re-
sponse to therapy, such as a decrease in fever
(placement of an indwelling epidural (or in-
trathecal) catheter in this group of patients
remains controversial) (Grade A).
5. Available data suggest that spinal anesthesia
may be safely performed in patients at risk for
low-grade transient bacteremia after dural
puncture (Grade B).
6. Epidural catheters should be removed in the
presence of local erythema and/or discharge;
there are no convincing data to suggest that
concomitant infection at remote sites or the ab-
sence of antibiotic therapy are risk factors for
infection.
7. A delay in diagnosis and treatment of major CNS
infections of even a few hours may significantly
worsen neurologic outcome (Grade B).

 

[dfk]

Sepsis is a relative contraindication to neuraxial anesthesia. RSI.

relative, not absolute. and jeff05 pointed that out in the article above (see no. 5). given this case, IMO, the benefits outweigh risks. besides, no infection at site of spinal (that we know of), nor do we know the "degree" of sepsis.

 

[excalibur]

relative, not absolute. and jeff05 pointed that out in the article above (see no. 5). given this case, IMO, the benefits outweigh risks. besides, no infection at site of spinal (that we know of), nor do we know the "degree" of sepsis.

Why even risk it? +2 on the documentation of surg emergency, RSI, extubate when awake.

For me the most amazing part of the original post was this...

"It's NOON and you've just finished your last scheduled case in one of the ortho rooms"

-Excalibur envious

 

[pgg]

hyperbaric spinal, sit 'em up and give 'em an iphone to watch a video.

[...]

relative, not absolute. and jeff05 pointed that out in the article above (see no. 5). given this case, IMO, the benefits outweigh risks. besides, no infection at site of spinal (that we know of), nor do we know the "degree" of sepsis.

She's been on antibiotics, presumably appropriate ones as directed by her 3 day old culture results. Nothing in the OP to imply anything more than a localized infection. Provided the patient doesn't have signs of overt bacteremia/sepsis (here it looks like she is not septic; her WBC of "80" is the only 1 of the 4 SIRS criteria she meets), I agree that a spinal would be OK.

But maybe a better question is, if you want to avoid a general, why is a spinal your regional technique of choice? If there's any thought in your head of perhaps introducing bacteria into the CSF, and you really want to stay with a regional technique, why not just do a simple popliteal/saphenous block? Stay away from the spine altogether.

In the real world, given a reassuring airway, I'd probably just RSI and tube her. I d on't believe she's especially high risk for a general, even accounting for her ~4 hr NPO period.

 

[Noyac]

Spinal OK
regional OK

I'd put her to sleep.

 

[SleepIsGood]

I agree with a regional technique

I don tthink a popliteal/sciatic will be sufficient alone. You will likely miss the saphenous. I say do the pop block, then supplement the saph with a infrapatellar saph block.

 

[aphistis]

surgeon documents that this is a surgical emergency.
RSI.
extubate when awake.

I agree with a regional technique

I don tthink a popliteal/sciatic will be sufficient alone. You will likely miss the saphenous. I say do the pop block, then supplement the saph with a infrapatellar saph block.

These two combined are exactly what we did. Our APS team did the pop/saph while the charge nurse was rounding up OR staff from lunch. Easy RSI, stable intraop, fully awake (unfortunately) before extubating. The big teaching point for me was making sure the surgeon and I both documented that the case was being done as a surgical emergency.

 

[Noyac]

These two combined are exactly what we did. Our APS team did the pop/saph while the charge nurse was rounding up OR staff from lunch. Easy RSI, stable intraop, fully awake (unfortunately) before extubating. The big teaching point for me was making sure the surgeon and I both documented that the case was being done as a surgical emergency.

What!
You did regional and an RSI and "unfortunately" she was awake for extubation.

I'm not following this at all.

 

[aphistis]

Why even risk it? +2 on the documentation of surg emergency, RSI, extubate when awake.

For me the most amazing part of the original post was this...

"It's NOON and you've just finished your last scheduled case in one of the ortho rooms"

-Excalibur envious

Don't worry, it's a rare occurrence. With add-ons, my room didn't finish until around 4:30 (which is still a lot better than some days I've had with ortho). A bunch of residents are gone this week, so it's basically staff cases all week. It's a nice change of pace from the 6-hour radius ORIF.

 

[aphistis]

What!
You did regional and an RSI and "unfortunately" she was awake for extubation.

I'm not following this at all.

Fair enough. For clarification, my plan was to do it under regional+MAC, but my attending preferred a general, so that's how we did it.

Since we had a little bit of downtime, our block team placed the blocks for post-op analgesia before we took her to the room. The "unfortunately" was just a tongue-in-cheek reflection on this lady's (less than) cheerful disposition.

 

[pgg]

These two combined are exactly what we did. Our APS team did the pop/saph while the charge nurse was rounding up OR staff from lunch. Easy RSI, stable intraop, fully awake (unfortunately) before extubating. The big teaching point for me was making sure the surgeon and I both documented that the case was being done as a surgical emergency.

Wait, why'd you give a patient a surgical block and put her to sleep? Popliteal/saphenous blocks are easy and reliable.

There are small (but unavoidable) risks with either GA or regional. I don't see the up side to doing both.

 

[Noyac]

Fair enough. For clarification, my plan was to do it under regional+MAC, but my attending preferred a general, so that's how we did it.

Since we had a little bit of downtime, our block team placed the blocks for post-op analgesia before we took her to the room. The "unfortunately" was just a tongue-in-cheek reflection on this lady's (less than) cheerful disposition.

I forget how ridiculous academics can be.

You have an APS team with their plan, a resident with his plan and an attending with another plan. What a cluster f*ck.

 

[aphistis]

Wait, why'd you give a patient a surgical block and put her to sleep? Popliteal/saphenous blocks are easy and reliable.

There are small (but unavoidable) risks with either GA or regional. I don't see the up side to doing both.

The honest answer here is "nobody here really knew what was going on, so rather than challenge him about doing it my way, I went along with the staff plan." Like Noyac said, it was a cluster from the start, and in this case I chose to go along with my attending's plan rather than fall on my sword for nothing.

My personal suspicion is that this wasn't anything even remotely approaching an emergency to begin with (she'd been stable on the floor for a week), and the surgeon was just working the system to squeeze another case in.

 

[Noyac]

My personal suspicion is that this wasn't anything even remotely approaching an emergency to begin with (she'd been stable on the floor for a week), and the surgeon was just working the system to squeeze another case in.

I doubt that. The surgeon was doing this case probono.
Now maybe he had somewhere to be but I don't think he was just adding a case.
Plus this is an IDDM with a WBC of 80. It can't wait! It goes now.

BTW, are you sure the WBC was 80? I don't recall ever seeing a count that high.

 

[pgg]

in this case I chose to go along with my attending's plan rather than fall on my sword for nothing.

Amen, choose your battles.

BTW, are you sure the WBC was 80? I don't recall ever seeing a count that high.

I took it as hyperbole/exaggeration; I don't think that even people dying of leukemia sludge-blood get that high.

 

[aphistis]

I doubt that. The surgeon was doing this case probono.
Now maybe he had somewhere to be but I don't think he was just adding a case.
Plus this is an IDDM with a WBC of 80. It can't wait! It goes now.

BTW, are you sure the WBC was 80? I don't recall ever seeing a count that high.

You're right; it's hard to tell what was really going on, but the surgeon probably isn't paying for a vacation home with this lady. And her white count? 6.3.

 

[proman]

I've seen a leukemia patient with a WBC of 750,000. Only complained of fatigue. The patients who get GCSF for granulocyte donation (instead of marrow) go up to 100,000 or so. Leukamoid reactions can definitely go to 80,000 but those patients typically aren't eating breakfast 4 hours before.

 

[drccw]

hx of IVDU? That's pretty much a contraindication for a MAC. Plus lumberjack breakfast.....

RSI... whether you do blocks before is up to you. If the surgeon is calling it an "emergency" then its straight to the OR and straight to sleep. Sounds like a soft call for an emergency (which most cases are). Sounds urgent but not emergent.

Rupture AAA emergent. Epidural hematoma. Emergent... Pus in the ankle... Urgent... Sounds like the surgeon needs a better understanding that needing to make a 330 tee time doesnt make a surgery an emergency...

 

[ozzie20]

I've seen a leukemia patient with a WBC of 750,000. Only complained of fatigue. The patients who get GCSF for granulocyte donation (instead of marrow) go up to 100,000 or so. Leukamoid reactions can definitely go to 80,000 but those patients typically aren't eating breakfast 4 hours before.

I think he meant that he's never seen an infection causing a WBC count of 80.

 

[Noyac]

I think he meant that he's never seen an infection causing a WBC count of 80.

Yes.

 

[proman]

Leukamoid reactions are in response to infection. And I was also answering pgg.

 

[Arch Guillotti]

I took it as hyperbole/exaggeration; I don't think that even people dying of leukemia sludge-blood get that high.

There is a thread over on sermo about a kid w/a WBC of 86.7

 

[pgg]

Leukamoid reactions are in response to infection. And I was also answering pgg.

I stand corrected ... never seen a white count that high.

 

[aphistis]

Found out this morning the 80k WBC was from an ankle tap. The surgeon didn't mention that yesterday, but at least he wasn't making the number up.

So the consensus seems to be that awake regional or RSI asleep were both reasonable plans, but doing both for this case was overkill?

 

[Mofeen]

Amen, choose your battles.




I took it as hyperbole/exaggeration; I don't think that even people dying of leukemia sludge-blood get that high.

Saw a young girl in her early twenties with a dead bowel from jejunem to rectum with a white count of 72K.

 

[periopdoc]

In my setting, my plan would have been identical to what ended up happening anyway. Surgeon documents emergent nature. 5 minutes to throw in a pop/sci and infrapatellar saph block then off to the room for RSI. Here are my reasons.

Surgeon documents emergent nature - obvious

Regional - for pain control. These are fast, easy, and reliable blocks and I will have a lot less hassle trying to figure out what opiate load the patient needs during a procedure that should last less than 15 minutes. If I were to go opiate only for pain control there is a good chance that this lady will eat up a lot of my PACU time trying to get comfy

RSI - I don't like MAC in these type of patients. No matter how good your block is, her coping skills are going to be non-existent and she will spend the whole case complaining and moving around. It would be just my luck that the surgeons would decide to use a thigh tourniquet. If the case goes long or she gets freaked out you are going to have to RSI her intraop anyways. I would prefer to avoid RSI while the surgeons are operating.


Now if I was in private practice and I didn't have to wait for an attending to show up for me to induce and intubate, I would give her a chance to prove me wrong about her coping skills and I would do regional plus MAC with RSI intraop prn.

Incidentally, if this was Harborview and I was going to go opiate only, I would likely bolus 250-500 of fent in preop and gauge her response. The typical Harborview IVDA pt takes somewhere in the range of 1000 fentanyl and 6-8 hydromorphone +/- ketamine for a 15-30 min ankle washout. I love when they are NPO and I throw in an LMA and start titrating the opiates to respiratory effort. My record for a 15 minute abscess drainage was 2000 fent and 20 hydromorphone. Patient woke up comfortable, alert, and breathing 12/ min.

- pod

 

[Planktonmd]

Now if I was in private practice and I didn't have to wait for an attending to show up for me to induce and intubate, I would give her a chance to prove me wrong about her coping skills and I would do regional plus MAC with RSI intraop prn.

- pod

In private practice (at least in my private practice) there is a simple formula:
Drug addict + Short surgery = General anesthesia.
They are never happy with the block, and they want their narcotics post op.
Many of them will pretend that your block is not working so why even bother?

 

[Noyac]

In private practice (at least in my private practice) there is a simple formula:
Drug addict + Short surgery = General anesthesia.
They are never happy with the block, and they want their narcotics post op.
Many of them will pretend that your block is not working so why even bother?

Bingo

 

[Jeff05]

MAC is contraindicated in a full stomach scenario (shlogging complainy moms after baby is out in c/s is a special situation)
it's either no meds or RSI.

 

[Noyac]

MAC is contraindicated in a full stomach scenario (shlogging complainy moms after baby is out in c/s is a special situation)
it's either no meds or RSI.

That's debatable.

Many here would call it academic dogma.

 

[Arch Guillotti]

That's debatable.

Many here would call it academic dogma.

I would call it dogma.