#Case_15 (10 kg) ovarian cyst

[DrAmir0078]

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Hi SDN Anesthesiologists,
I hope you are doing well. My case - writing it from the OR now :
16 years old female 50 kg, with a history of growing abdominal distention over the last 3 months, no PMH, labs within normal.
Consideration and induction :
- Aortocaval consideration, left lateral titlt - PR was 124 bpm and with left titlt + bimanual left compression of the abdomen - PR within 70+ (if you remember my consideration about this in prior posts - it works amazingly).

- Hydatid cysts precautions - adrenaline and HC are handy + ephedrine.

- Intestinal Obstruction precautions - no vomiting today, but mild dehydration - she was in the ward for the last 3 days - correction of mild.

Prior to induction 1 Lt crystaloid given, NS

- Another 0.5 Lt was in and induction done, Ketamine 30 mg, Propofol 50 mg slowly and rocuronium 25 mg (fasting over 8 hours) - no Sux available, plus sevoflurane 4% inhalational, but prior with 3 minutes preoxygenation with fitted face mask.

- induction and ETT smoothly, on VCV and peak pressure was like 18 cm H2O.
Another 0.5 Lt, Ringer given of crystaloid, Ringer. Maintained with isoflurane 1.3% and given paracetamol at the end of operation.

Operation last 1 hour and a half; huge ovarian cyst with suction 7 Lt of clear fluids and kept 3 Lt like for surgical manipulation. No hypotension during the operation, regular sinus rythm of 80 - 90 bpm.

At the end of the procedure, bilateral rectus sheath block done under Ultrasound. Hard to visualize the rectus muscles. Her abdominal cavity was like empty, all viscera were shifted bilaterally.

The problem with emergence, she took like over 30 minutes without efforts for breathing, she got bradycardia at this time and treated with atropine.

Fluid total was 2.5 Lts and we started glucose water 200 cc and Glucose saline afterwards with 250.

Urine output was 1.2 Lt.

Gradually she started gain consciousness, and extubation done.

Kept 1 hour in the recovery, until she starts talking and CBC and electrolytes sent - looks fine to me. Sent to the ward.

Delayed recovery was questionable, but without ABG, and not to say glucometer for glucose check, it was by assumption.

I was worried a bit, she complains of blurring vision, but improved afterwards.

A question here, with such fluid replacement or resuscitation - weren't wise? Such 10 Lts of fluid in her cyst wasn't considered from the loss as it is gradually built up and body compensate. I feard of hypovolemia, but my suspecion of IO was treated with fluid of 1.5 Lt at least prior to pushing meds.

What else should've done?

Her electrolytes just arrived and they were in normal range!

Thanks for reading me.

Amir
View attachment 357028

 

[Hoya11]

Hi SDN Anesthesiologists,
I hope you are doing well. My case - writing it from the OR now :
16 years old female 50 kg, with a history of growing abdominal distention over the last 3 months, no PMH, labs within normal.
Consideration and induction :
- Aortocaval consideration, left lateral titlt - PR was 124 bpm and with left titlt + bimanual left compression of the abdomen - PR within 70+ (if you remember my consideration about this in prior posts - it works amazingly).

- Hydatid cysts precautions - adrenaline and HC are handy + ephedrine.

- Intestinal Obstruction precautions - no vomiting today, but mild dehydration - she was in the ward for the last 3 days - correction of mild.

Prior to induction 1 Lt crystaloid given, NS

- Another 0.5 Lt was in and induction done, Ketamine 30 mg, Propofol 50 mg slowly and rocuronium 25 mg (fasting over 8 hours) - no Sux available, plus sevoflurane 4% inhalational, but prior with 3 minutes preoxygenation with fitted face mask.

- induction and ETT smoothly, on VCV and peak pressure was like 18 cm H2O.
Another 0.5 Lt, Ringer given of crystaloid, Ringer. Maintained with isoflurane 1.3% and given paracetamol at the end of operation.

Operation last 1 hour and a half; huge ovarian cyst with suction 7 Lt of clear fluids and kept 3 Lt like for surgical manipulation. No hypotension during the operation, regular sinus rythm of 80 - 90 bpm.

At the end of the procedure, bilateral rectus sheath block done under Ultrasound. Hard to visualize the rectus muscles. Her abdominal cavity was like empty, all viscera were shifted bilaterally.

The problem with emergence, she took like over 30 minutes without efforts for breathing, she got bradycardia at this time and treated with atropine.

Fluid total was 2.5 Lts and we started glucose water 200 cc and Glucose saline afterwards with 250.

Urine output was 1.2 Lt.

Gradually she started gain consciousness, and extubation done.

Kept 1 hour in the recovery, until she starts talking and CBC and electrolytes sent - looks fine to me. Sent to the ward.

Delayed recovery was questionable, but without ABG, and not to say glucometer for glucose check, it was by assumption.

I was worried a bit, she complains of blurring vision, but improved afterwards.

A question here, with such fluid replacement or resuscitation - weren't wise? Such 10 Lts of fluid in her cyst wasn't considered from the loss as it is gradually built up and body compensate. I feard of hypovolemia, but my suspecion of IO was treated with fluid of 1.5 Lt at least prior to pushing meds.

What else should've done?

Her electrolytes just arrived and they were in normal range!

Thanks for reading me.

Amir
View attachment 357028

Thanks for posting!

Maybe it was the 1.3% iso taking a while to come off? Usually I run 0.7-0.8% (but i rarely ever use iso)

Sometimes I have seen that breathing doesnt return until sevo/iso level is way down like less than 0.6

Especially after paralysis.

Whenever I can not get someone to breath, I do the following:

Ensure she was adequately reversed from Rocuronium.

Ensure she is not overnarcotized and possibly give Narcan.

Get the inhalational anesthesia off as rapidly as possible.

Provide"stimulation" meaning either wiggle the tube, press on the tube cuff, or give jaw thrust.

Often I just leave the ventilator on and the gas off and o2 flows all the way up while stimulating the patient, and eventually they come around.

All in all 30 minutes is not such a big delay. Especially using Iso.

Once you started the case with sevo I would have just stuck with that. I would not see the need to change to iso.

 

[Blackmateria]

Iso is cheaper though no? Agree would not switch to it unless there are cost considerations.

Relative hypothermia is also a classic cause of delayed emergence, do you have active warming available?

 

[DrAmir0078]

Thanks for posting!

Maybe it was the 1.3% iso taking a while to come off? Usually I run 0.7-0.8% (but i rarely ever use iso)

Sometimes I have seen that breathing doesnt return until sevo/iso level is way down like less than 0.6

Especially after paralysis.

Whenever I can not get someone to breath, I do the following:

Ensure she was adequately reversed from Rocuronium.

Ensure she is not overnarcotized and possibly give Narcan.

Get the inhalational anesthesia off as rapidly as possible.

Provide"stimulation" meaning either wiggle the tube, press on the tube cuff, or give jaw thrust.

Often I just leave the ventilator on and the gas off and o2 flows all the way up while stimulating the patient, and eventually they come around.

All in all 30 minutes is not such a big delay. Especially using Iso.

Once you started the case with sevo I would have just stuck with that. I would not see the need to change to iso.

Thanks for the advice. I did actually off Isoflurane with the start of suturing skin - mid line incision, as she wasn't breathing at all and swtich it to SIMV/PSV. It took like another 10 minutes for rectus sheath block. We tried to stimulate and jaw thrust, she had interestingly good power, very limited lacrimation - moving her arms - but no ability to open her eyes, with no ventilation effort. At this time we gave reversal neostigmine + atropine (2.5 mg/1.2 mg) - prior we had bradycardia following the rectus sheath block (we have used bupivacaine 15 ml, 0.25%), but normotensive - her pulse reached 48 - 50 bpm (we feard of deterioration), so we gave her 0.6 mg atropine. Even we tried to lower RR for hypercapnia induce ventilation (of course without capnography) and it didn't work, but we institute reversal then she started breathing spontaneously, but again limited vT, she was then fighting ETT and we extubated her on CPAP and jaw thrust for 3 minutes and then she was fine and saturation kept 100% on room air.

As I mentioned, I kept her an hour in the recovery, until she was fully awake and could talk and see my glasses, and free from pain.

So, I am recalling now = 1.2 mg + 0.6 mg atropine, weren't we close to anticholinergic syndrome; she was not agitated - briefly during stimulation and extubation - and she was a bit with blurred vision, she can count fingers, but wasn't able to recognize I was wearing glasses or not. She stayed calm with G5%NS0.45% infusion and with level down her head to supine and flexing her hip-knee.

 

[DrAmir0078]

Iso is cheaper though no? Agree would not switch to it unless there are cost considerations.

Relative hypothermia is also a classic cause of delayed emergence, do you have active warming available?

Yes, indeed
Sevoflurane is expensive and we keep it for inhalational induction only. Hypothermia was considered, we immediately wrapped her up with blanket. Unfortunately we don't have forced air warming blankets.

 

[coffeebythelake]

Nice case summary and considerations.

How much opioid did she get in the case? If patient makes no respiratory efforts despite a reasonable EtCO2 that's what I'm thinking.

 

[DrAmir0078]

Nice case summary and considerations.

How much opioid did she get in the case? If patient makes no respiratory efforts despite a reasonable EtCO2 that's what I'm thinking.

I didn't bring or request any opioid, only requested the patient relative to buy paracetamol vial from outside pharmacy right across the street of the hospital. I believe my Colleague added Acupan with Paracetamol and both - if true - were given at the end of the procedure. The patient didn't show any wearing off from muscle relaxant during the operation time, usually 25 mg of rocuronium and with our storage and drugs efficacy like won't last over 30 minutes. We thought of giving blood "my PGY1 brought this idea", I didn't agree, her face and palms still saying "I am not that pale"; her post operation CBC Hb was 10.9 mg/dl, and she was skinny after removing the cyst; I am not sure if you have seen the MRI image attached, and I am not sure if such cyst affect her lungs / diaphragm as it was pushing up. I applied PEEP during the operation, I did manual recruitment of the lung, and after extubation again tried recruitment and my PGY1 was saying "left side of the lung has diminished air entry", and when I was recruiting again, he starts hearing better. I do not know what happens in the physiology, but I tried my best. Today I visited her, she was fine, she walks couple time and complaining about how empty her abdomen.

 

[Hoya11]

I didn't bring or request any opioid, only requested the patient relative to buy paracetamol vial from outside pharmacy right across the street of the hospital. I believe my Colleague added Acupan with Paracetamol and both - if true - were given at the end of the procedure. The patient didn't show any wearing off from muscle relaxant during the operation time, usually 25 mg of rocuronium and with our storage and drugs efficacy like won't last over 30 minutes. We thought of giving blood "my PGY1 brought this idea", I didn't agree, her face and palms still saying "I am not that pale"; her post operation CBC Hb was 10.9 mg/dl, and she was skinny after removing the cyst; I am not sure if you have seen the MRI image attached, and I am not sure if such cyst affect her lungs / diaphragm as it was pushing up. I applied PEEP during the operation, I did manual recruitment of the lung, and after extubation again tried recruitment and my PGY1 was saying "left side of the lung has diminished air entry", and when I was recruiting again, he starts hearing better. I do not know what happens in the physiology, but I tried my best. Today I visited her, she was fine, she walks couple time and complaining about how empty her abdomen.

so you gave no opioids for this case?

 

[DrAmir0078]

so you gave no opioids for this case?

Except Acupan and I doubt it - it was only Paracetamol. We do not have access to narcotics on emergency cases, unless we request formally from the department to supply us with 10 ml - 0.5 mg total Fentanyl and nothing else we have so far; and I personally as a team leader didn't request yesterday Fentanyl - and although I had couple cc of Fentanyl in an empty ketamine vial - and it age around 1 year (I used it for top top emergency procedure - it is in my personal anesthesia carrying bag with other drugs and equipments).

 

[IlDestriero]

It amazes me what you guys can do with essentially no drugs or resources, just as you must be amazed that we have immediate access to every drug and tool that money can buy. I used to keep an emergency 500mg of Ketamine in a go bag years ago to run to an emergency intubation/code/etc. I actually found it recently throwing out a lot of old stuff from my military days.
Sounds like you did a good job! Some delayed emergence and post op confusion is par for the course for a teenager, alternating with waking up too fast and being combative or overly emotional.

 

[DrAmir0078]

It amazes me what you guys can do with essentially no drugs or resources, just as you must be amazed that we have immediate access to every drug and tool that money can buy. I used to keep an emergency 500mg of Ketamine in a go bag years ago to run to an emergency intubation/code/etc. I actually found it recently throwing out a lot of old stuff from my military days.
Sounds like you did a good job! Some delayed emergence and post op confusion is par for the course for a teenager, alternating with waking up too fast and being combative or overly emotional.

I am thankful for your insight. I believe military service was amazing to give you an extra experience in field dynamic time.
I have noticed too, teenage and pediatrics have some time delayed emergence; and I think as personally thinks farther from this point. Although limited sources, and when I am recalling the case and I believe Dr. @coffeebythelake insight above let me think more about it. I am not sure, but my mind keeps thinking, and I am wondering her body skinny look especially proximal muscle wasting of her shoulders, arm and skinny face, even skinny arm; am I pointing out to muscular disorder like myotonia dystrophica like? or even undiagnosed yet Myasthenia gravis. Giving rocuronium like 25 mg was may be a lot or I don't know if I gave her Sux what would happen. Here, I admit lack the tools and resources and makes me feel like I am "fool" and not ready to hold such future responsibility as Anesthesiologist without studying, managing, and discussing every such case. It scares me not to be responsible and I can't just be "defensive ****** guy" without actual understanding of any consideration. I love anesthesia and I am eager to learn it in an alphabetical way, but and I hate but, we lack forward navigation of what to study and what to focus, it is like a chaotic environment, pushing you in an ocean of limited resources to survive.

 

[shepardsun]

I am thankful for your insight. I believe military service was amazing to give you an extra experience in field dynamic time.
I have noticed too, teenage and pediatrics have some time delayed emergence; and I think as personally thinks farther from this point. Although limited sources, and when I am recalling the case and I believe Dr. @coffeebythelake insight above let me think more about it. I am not sure, but my mind keeps thinking, and I am wondering her body skinny look especially proximal muscle wasting of her shoulders, arm and skinny face, even skinny arm; am I pointing out to muscular disorder like myotonia dystrophica like? or even undiagnosed yet Myasthenia gravis. Giving rocuronium like 25 mg was may be a lot or I don't know if I gave her Sux what would happen. Here, I admit lack the tools and resources and makes me feel like I am "fool" and not ready to hold such future responsibility as Anesthesiologist without studying, managing, and discussing every such case. It scares me not to be responsible and I can't just be "defensive ****** guy" without actual understanding of any consideration. I love anesthesia and I am eager to learn it in an alphabetical way, but and I hate but, we lack forward navigation of what to study and what to focus, it is like a chaotic environment, pushing you in an ocean of limited resources to survive.

I'm always so impressed by your work ethic, desire to learn, and positive attitude, despite the limited clinical resources you have available to you. I promise you this, 90% of us here on this board would be unable to function well in your environment, and conversely, you could come over here and within a year be one of the top anesthesiologists of any group you joined.

 

[DrAmir0078]

I'm always so impressed by your work ethic, desire to learn, and positive attitude, despite the limited clinical resources you have available to you. I promise you this, 90% of us here on this board would be unable to function well in your environment, and conversely, you could come over here and within a year be one of the top anesthesiologists of any group you joined.

Thank you for allowing me and bare my feelings and thoughts, such fruits and pearls I am learning here make a difference in my practice; it means a lot to me and to karma you all in return in a way or another, it helps to save others lives, and I am so grateful to be part of this family.
I spoke with the surgery resident and he said, they are discharging her tomorrow, she is very well. I don't know why the MRI didn't go through here. I will attach it again.

 

[abolt18]

Thank you for allowing me and bare my feelings and thoughts, such fruits and pearls I am learning here make a difference in my practice; it means a lot to me and to karma you all in return in a way or another, it helps to save others lives, and I am so grateful to be part of this family.
I spoke with the surgery resident and he said, they are discharging her tomorrow, she is very well. I don't know why the MRI didn't go through here. I will attach it again. View attachment 357054

Not much room for other organs in there! Yikes!

 

[ethilo]

Fastest way to get someone to breathe again without Narcan is to be certain the'll they have no lingering effects of paralytic, preoxygenate them, then just shut the ventilator off. No faster way to increase the CO2 needed for respiratory drive than to make the patient apneic.

 

[GassYous]

Fastest way to get someone to breathe again without Narcan is to be certain the'll they have no lingering effects of paralytic, preoxygenate them, then just shut the ventilator off. No faster way to increase the CO2 needed for respiratory drive than to make the patient apneic.

I like to decrease rr late in the case to let the co2 build

 

[coffeebythelake]

Fastest way to get someone to breathe again without Narcan is to be certain the'll they have no lingering effects of paralytic, preoxygenate them, then just shut the ventilator off. No faster way to increase the CO2 needed for respiratory drive than to make the patient apneic.

Or you can disconnect the co2 absorber. That way you still get the sevo off but just rebreathing a lot of the co2

 

[sevoflurane]

Hi SDN Anesthesiologists,
I hope you are doing well. My case - writing it from the OR now :
16 years old female 50 kg, with a history of growing abdominal distention over the last 3 months, no PMH, labs within normal.
Consideration and induction :
- Aortocaval consideration, left lateral titlt - PR was 124 bpm and with left titlt + bimanual left compression of the abdomen - PR within 70+ (if you remember my consideration about this in prior posts - it works amazingly).

- Hydatid cysts precautions - adrenaline and HC are handy + ephedrine.

- Intestinal Obstruction precautions - no vomiting today, but mild dehydration - she was in the ward for the last 3 days - correction of mild.

Prior to induction 1 Lt crystaloid given, NS

- Another 0.5 Lt was in and induction done, Ketamine 30 mg, Propofol 50 mg slowly and rocuronium 25 mg (fasting over 8 hours) - no Sux available, plus sevoflurane 4% inhalational, but prior with 3 minutes preoxygenation with fitted face mask.

- induction and ETT smoothly, on VCV and peak pressure was like 18 cm H2O.
Another 0.5 Lt, Ringer given of crystaloid, Ringer. Maintained with isoflurane 1.3% and given paracetamol at the end of operation.

Operation last 1 hour and a half; huge ovarian cyst with suction 7 Lt of clear fluids and kept 3 Lt like for surgical manipulation. No hypotension during the operation, regular sinus rythm of 80 - 90 bpm.

At the end of the procedure, bilateral rectus sheath block done under Ultrasound. Hard to visualize the rectus muscles. Her abdominal cavity was like empty, all viscera were shifted bilaterally.

The problem with emergence, she took like over 30 minutes without efforts for breathing, she got bradycardia at this time and treated with atropine.

Fluid total was 2.5 Lts and we started glucose water 200 cc and Glucose saline afterwards with 250.

Urine output was 1.2 Lt.

Gradually she started gain consciousness, and extubation done.

Kept 1 hour in the recovery, until she starts talking and CBC and electrolytes sent - looks fine to me. Sent to the ward.

Delayed recovery was questionable, but without ABG, and not to say glucometer for glucose check, it was by assumption.

I was worried a bit, she complains of blurring vision, but improved afterwards.

A question here, with such fluid replacement or resuscitation - weren't wise? Such 10 Lts of fluid in her cyst wasn't considered from the loss as it is gradually built up and body compensate. I feard of hypovolemia, but my suspecion of IO was treated with fluid of 1.5 Lt at least prior to pushing meds.

What else should've done?

Her electrolytes just arrived and they were in normal range!

Thanks for reading me.

Amir
View attachment 357028

Really fun to see your anesthesia progression over the years despite vastly different location and anesthesia resources. You are doing great and have a fantastic attitude towards the profession. Good job. 👍🏽

 

[ethilo]

Or you can disconnect the co2 absorber. That way you still get the sevo off but just rebreathing a lot of the co2

Nice, that's next level!! 😂

 

[Dantrolene FC]

Or you can disconnect the co2 absorber. That way you still get the sevo off but just rebreathing a lot of the co2

But then you’re rebreathing sevoflurane.

 

[coffeebythelake]

But then you’re rebreathing sevoflurane.

why? the co2 absorber has nothing to do with the exhaust

 

[abolt18]

If you have the flows up high enough to rapidly blow off sevo, then you have them high enough to blow off all that CO2 as well and removing the absorber is moot.

 

[GassYous]

So I had a bunch of people in residency put the flows to like 15-20 a minute which I thought was wasteful and unnecessary. I just put it at minute ventilation and have no problem getting gas off. What's the point?

 

[coffeebythelake]

If you have the flows up high enough to rapidly blow off sevo, then you have them high enough to blow off all that CO2 as well and removing the absorber is moot.

Yes high fresh gas flows will direct more of the existing gases in the circuit to exhaust. And it also helps create the gradient between blood and alveolar sevo concentrations. But understand that flows are only part of the equation when it comes to "blowing off the sevo". Once the gradient is maximal (the inhaled sevo concentration = 0) then using high fresh gas flows don't matter so much any more.

Going back to what i said earlier.. RR x TV matter. And if you hyperventilate you invariably drive down the CO2. And if you use the same ventilation strategy but disconnect the CO2 absorber the CO2 doesn't come down so quickly. You would be doing this before going way up on your fresh gas flows.

To illustrate:
10 min from end of case, pt at 0.7 MAC gas with ETCO2 of 30. Pull the co2 absorber out to quickly raise the ETCO2. 5 min from end of case, pt at 0.7 MAC gas and ETCO2 of 50. Proceed to go way up on FGF and hyperventilate to blow off the sevo. Fin.

 

[MirrorTodd]

That's insane. That cyst was 1/5th of her body weight.

 

[FiO2@21]

Hi SDN Anesthesiologists,
I hope you are doing well. My case - writing it from the OR now :
16 years old female 50 kg, with a history of growing abdominal distention over the last 3 months, no PMH, labs within normal.
Consideration and induction :
- Aortocaval consideration, left lateral titlt - PR was 124 bpm and with left titlt + bimanual left compression of the abdomen - PR within 70+ (if you remember my consideration about this in prior posts - it works amazingly).

- Hydatid cysts precautions - adrenaline and HC are handy + ephedrine.

- Intestinal Obstruction precautions - no vomiting today, but mild dehydration - she was in the ward for the last 3 days - correction of mild.

Prior to induction 1 Lt crystaloid given, NS

- Another 0.5 Lt was in and induction done, Ketamine 30 mg, Propofol 50 mg slowly and rocuronium 25 mg (fasting over 8 hours) - no Sux available, plus sevoflurane 4% inhalational, but prior with 3 minutes preoxygenation with fitted face mask.

- induction and ETT smoothly, on VCV and peak pressure was like 18 cm H2O.
Another 0.5 Lt, Ringer given of crystaloid, Ringer. Maintained with isoflurane 1.3% and given paracetamol at the end of operation.

Operation last 1 hour and a half; huge ovarian cyst with suction 7 Lt of clear fluids and kept 3 Lt like for surgical manipulation. No hypotension during the operation, regular sinus rythm of 80 - 90 bpm.

At the end of the procedure, bilateral rectus sheath block done under Ultrasound. Hard to visualize the rectus muscles. Her abdominal cavity was like empty, all viscera were shifted bilaterally.

The problem with emergence, she took like over 30 minutes without efforts for breathing, she got bradycardia at this time and treated with atropine.

Fluid total was 2.5 Lts and we started glucose water 200 cc and Glucose saline afterwards with 250.

Urine output was 1.2 Lt.

Gradually she started gain consciousness, and extubation done.

Kept 1 hour in the recovery, until she starts talking and CBC and electrolytes sent - looks fine to me. Sent to the ward.

Delayed recovery was questionable, but without ABG, and not to say glucometer for glucose check, it was by assumption.

I was worried a bit, she complains of blurring vision, but improved afterwards.

A question here, with such fluid replacement or resuscitation - weren't wise? Such 10 Lts of fluid in her cyst wasn't considered from the loss as it is gradually built up and body compensate. I feard of hypovolemia, but my suspecion of IO was treated with fluid of 1.5 Lt at least prior to pushing meds.

What else should've done?

Her electrolytes just arrived and they were in normal range!

Thanks for reading me.

Amir
View attachment 357028

What was her minute ventilation on the ventilator?

Since you do not have ETCO2 monitoring, I'm thinking that this small woman's CO2 production under general anesthesia was much lower than what you're used to. So you might have driven her CO2 lower than you thought you would.

Hypoglycemia was a great thought and delayed emergence could have definitely been secondary to that. You said electrolyte panel was normal, but that was after you gave the glucose, correct?