CASES from call last night for discussion :-)

[amyl]

1. 47 yo female w h/o leukodystrophy and mitochondrial complex IV deficiency, OSA c/w CPAP, symptomatic peripheral neuropathy, intermittent hypoglycemia for excisions of multiple areas of melanoma over Right thigh an lower leg. surgeon says it will take about an hour or so.
-- w/u? plan? concerns?

2. 59 yo male w h/o charchot marie tooth dse, protein C deficiency for transurethral unroofing of prostatic abscess. no signs of systemic infection on PE.
-- w/u? plan? concerns?

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[nap$ter]

1. 47 yo female w h/o leukodystrophy and mitochondrial complex IV deficiency, OSA c/w CPAP, symptomatic peripheral neuropathy, intermittent hypoglycemia for excisions of multiple areas of melanoma over Right thigh an lower leg. surgeon says it will take about an hour or so.
-- w/u? plan? concerns?

2. 59 yo male w h/o charchot marie tooth dse, protein C deficiency for transurethral unroofing of prostatic abscess. no signs of systemic infection on PE.
-- w/u? plan? concerns?

w/u? - baseline function, etc...

1. real hypoglycemia? - book for insulinoma resection first.

then - hand surgeon a nasal cannula and 1/2 the toxic dose of bupivicaine - tell him to do it under local.

2. tell him he's going to be in the ICU a while. 2 large bore IV's, aline, prop/roc/tube. watch out for PE. prepare for systemic toxicity/septic physiology when urology unleashes pus into the systemic circulation through prostatic venous plexi.

 

[amyl]

thanks for playing
1. way too wide excisions for local and crazy anxious patient that would never go for local.

 

[dhb]

1. Fem + sciatic block
2. Pent sux tube

 

[nap$ter]

thanks for playing
1. way too wide excisions for local and crazy anxious patient that would never go for local.

thought you might say that.

document baseline neurologic exam. document thorough risk/benefit discussion. FNB, sciatic if going medial in the lower leg, LMA, minimize resp depressants.

 

[nap$ter]

1. Fem + sciatic block
2. Pent sux tube

really?

 

[dhb]

really?

Operative charts were reviewed in 86 patients with Charcot-Marie-Tooth disease, a condition characterized by chronic muscular denervation. A total of 161 surgical procedures was performed. Major complications were few, and only one operative death occurred, unrelated to anaesthesia. Succinylcholine and malignant hyperthermia triggering agents were used in 41 (48%) and 77 (90%) patients, respectively, without untoward effects. Contrary to previous reports, this survey supports the safe use of succinylcholine and MH triggering agents in this disease.

http://www.springerlink.com/content/c466832h02r82180/

 

[amyl]

my bad: i should have explained that there were also a couple inguinal lymph nodes to extract....

 

[nap$ter]

Operative charts were reviewed in 86 patients with Charcot-Marie-Tooth disease, a condition characterized by chronic muscular denervation. A total of 161 surgical procedures was performed. Major complications were few, and only one operative death occurred, unrelated to anaesthesia. Succinylcholine and malignant hyperthermia triggering agents were used in 41 (48%) and 77 (90%) patients, respectively, without untoward effects. Contrary to previous reports, this survey supports the safe use of succinylcholine and MH triggering agents in this disease.

http://www.springerlink.com/content/c466832h02r82180/

2 things interesting about that study:

1 - who were the cowboys giving sux to most of these patients? sounds like most of em had symptomatic muscular denervation at the time of administration - were these all medical errors?

2 - they got away with it - or did they? if they were bold/ignorant enough to give sux, mebbe they weren't looking for t-wave changes, cuppla pvc's crossing the screen didn't make it into the record.

just because you can, doesn't mean you should. i would still avoid sux, because there are reasonable alternatives. as they pointed out, no one has measured change in potassium in CMTD with sux. maybe you get away with it 200 times, only kill one in 200?

 

[urge]

1. 47 yo female w h/o leukodystrophy and mitochondrial complex IV deficiency, OSA c/w CPAP, symptomatic peripheral neuropathy, intermittent hypoglycemia for excisions of multiple areas of melanoma over Right thigh an lower leg. surgeon says it will take about an hour or so.
-- w/u? plan? concerns?

2. 59 yo male w h/o charchot marie tooth dse, protein C deficiency for transurethral unroofing of prostatic abscess. no signs of systemic infection on PE.
-- w/u? plan? concerns?

Spinal*2

 

[IlDestriero]

There's no way I would give #2 sux. No evidence of MH risk, but hyperkalemia is a distinct possibility.

2 things interesting about that study:

1 - who were the cowboys giving sux to most of these patients? sounds like most of em had symptomatic muscular denervation at the time of administration - were these all medical errors?

2 - they got away with it - or did they? if they were bold/ignorant enough to give sux, mebbe they weren't looking for t-wave changes, cuppla pvc's crossing the screen didn't make it into the record.

just because you can, doesn't mean you should. i would still avoid sux, because there are reasonable alternatives. as they pointed out, no one has measured change in potassium in CMTD with sux. maybe you get away with it 200 times, only kill one in 200?

 

[Idiopathic]

spinal*2

+1

 

[amyl]

pt #1 refused spinal.... no way no how was she going for that... claims her peripheral neuropathy worsened after prior epidural. so we LMA'ed her and ran TIVA. flushed the machine as per MH protocol. she could not have sux or VA but propofol is ok. complex II dse is the one that carries a higher risk of propofol infusion syndrome. she did well.
#2 had no apparent lung envolvlement -- functional class I-II, no h/o DVT or PE so no further work up. no spinal, they were gonna take too long and he did have an abscess, granted no signs of systemic infection but why risk it. general for him. i dont think he needed an aline, whats the indication?

 

[urge]

Why no gas on the first patient?