cases

[amyl]

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1. elderly pt with positive cath (occlusion of rca and lad) but failed angio/stenting and no remaining targets for cabg (they have all been harvested so her cardiologist suggested medical management at her last visit, COPD w FEV1/FVC 30%, PPM/AICD she says was just checked and didn't know what it was placed for. she arrested after her first cabg. also, her family says after her last surgery they messed up her arm (which is totally scarred) because something happened with her heart and they pushed epinephrine (yes they knew) in her IV and it infiltrated -- now for lap possible/probably open exploration for severe abdominal pain with ambigous CT. she is febrile but hemodynamically stable.
-- plan?
2. aged pt admitted w DKA a couple days ago preceeded by pneumonia, moderate COPD, MI in march but echo did not show any WMA. sugars now controlled. saturations on 4L nasal cannula 88-89% showing increased work of breathing, peripheral edema, wheezy lungs. pt is septic and in renal failure, urologist thinks its urosepsis and obstructive uropathy d/t large kidney stone. he is febrile but hemodynamically stable. surgeon says he has to cysto and try and retrieve or push up the stone now despite the pts condition but is okay with a spinal or just an LMA if worried about his condition.
--thoughts?
3. over 90 year old pt w HTN, DM, CAD, COPD, several CVAs, dementia s/p MI 3 weeks ago now for gamma nailing for acute hip fracture?
-- plan?

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[dhb]

1. elderly pt with positive cath (occlusion of rca and lad) but failed angio/stenting and no remaining targets for cabg (they have all been harvested so her cardiologist suggested medical management at her last visit, COPD w FEV1/FVC 30%, PPM/AICD she says was just checked and didn't know what it was placed for. she arrested after her first cabg. also, her family says after her last surgery they messed up her arm (which is totally scarred) because something happened with her heart and they pushed epinephrine (yes they knew) in her IV and it infiltrated -- now for lap possible/probably open exploration for severe abdominal pain with ambigous CT. she is febrile but hemodynamically stable.
-- plan?
2. aged pt admitted w DKA a couple days ago preceeded by pneumonia, moderate COPD, MI in march but echo did not show any WMA. sugars now controlled. saturations on 4L nasal cannula 88-89% showing increased work of breathing, peripheral edema, wheezy lungs. pt is septic and in renal failure, urologist thinks its urosepsis and obstructive uropathy d/t large kidney stone. he is febrile but hemodynamically stable. surgeon says he has to cysto and try and retrieve or push up the stone now despite the pts condition but is okay with a spinal or just an LMA if worried about his condition.
--thoughts?
3. over 90 year old pt w HTN, DM, CAD, COPD, several CVAs, dementia s/p MI 3 weeks ago now for gamma nailing for acute hip fracture?
-- plan?

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1) Her cardiologist is a rockstar 🙄, a line pent sux tube TAP block

2) Gotta do what you gotta do if not agitated i'd do a spinal if uncooperative GETA

3) LMA facia iliaca block smooth sailing

 

[IlDestriero]

1. elderly pt with positive cath (occlusion of rca and lad) but failed angio/stenting and no remaining targets for cabg (they have all been harvested so her cardiologist suggested medical management at her last visit, COPD w FEV1/FVC 30%, PPM/AICD she says was just checked and didn't know what it was placed for. she arrested after her first cabg. also, her family says after her last surgery they messed up her arm (which is totally scarred) because something happened with her heart and they pushed epinephrine (yes they knew) in her IV and it infiltrated -- now for lap possible/probably open exploration for severe abdominal pain with ambigous CT. she is febrile but hemodynamically stable.
-- plan?
2. aged pt admitted w DKA a couple days ago preceeded by pneumonia, moderate COPD, MI in march but echo did not show any WMA. sugars now controlled. saturations on 4L nasal cannula 88-89% showing increased work of breathing, peripheral edema, wheezy lungs. pt is septic and in renal failure, urologist thinks its urosepsis and obstructive uropathy d/t large kidney stone. he is febrile but hemodynamically stable. surgeon says he has to cysto and try and retrieve or push up the stone now despite the pts condition but is okay with a spinal or just an LMA if worried about his condition.
--thoughts?
3. over 90 year old pt w HTN, DM, CAD, COPD, several CVAs, dementia s/p MI 3 weeks ago now for gamma nailing for acute hip fracture?
-- plan?

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Do you work at Eisenhower? That's the daily grind in Palm Springs.😉

 

[ssmallz]

1) Preop A line, adequate large bore access, pressor drawn up and ready to go. Touch of prop, whiff of gas, roc and tube.

2) I'd delay this case for pulm optimization. She could benefit from a few more days of ABx and maybe some diuresis. If it absolutely has to go now, spinal would be the way to go with a neo drip in line. I'm not putting a tube in this pt b/c its never coming out.

3) What does the stress and echo say? If good this is a standard hip, if not a-line could be a good idea. No sense in delaying because you can't decrease her periop risk by waiting 2 or 3 days so just fix the hip.

 

[lushmd]

As regards a spinal anesthetic for the second case (cystoscopy) is there any concern for:

(1) Sympathectomy in a septic patient
(2) Entering the subarachnoid space in a septic patient

Personally, I'd go with GETA.

 

[Idiopathic]

(1) art line, 2 iv, something-something-tube
can (2) get a perc nephrostomy with IR followed by a few days of optimization and then GETA
(3) palliative care consult

 

[cchoukal]

(1) art line, 2 iv, something-something-tube

Love it. Does that stand for "something white, then something purple"?

 

[pgg]

(3) palliative care consult

A troch nail is palliative ...

 

[ssmallz]

As regards a spinal anesthetic for the second case (cystoscopy) is there any concern for:

(1) Sympathectomy in a septic patient
(2) Entering the subarachnoid space in a septic patient

Personally, I'd go with GETA.

Sympathectomy - concerned but can be neutralized w/pressors of choice. I'd personally use 0.5% bupi instead of the heavy stuff b/c I feel like I get more hemodynamic stability.

Subarachnoid space - yea she's septic and she needs more optimization before surgery. If she absolutely positively has to go now and can't wait you've gotta weigh the risks and benefits of a spinal vs GETA. A spinal risks possible infection while GETA risks likely post op ventilation in a pt w/weak lungs. My thinking is that this pt will be on ABx post op and theres a small risk of infection. Compare this to the more likely risk of prolonged post op ventilation and I think the risk of infection is justified. I don't think it's wrong to go GETA and avoid the risk or infection in a septic pt but I'm just weighing the risks and benefits and this is my perspective.

 

[jwk]

1) Preop A line, adequate large bore access, pressor drawn up and ready to go. Touch of prop, whiff of gas, roc and tube.

2) I'd delay this case for pulm optimization. She could benefit from a few more days of ABx and maybe some diuresis. If it absolutely has to go now, spinal would be the way to go with a neo drip in line. I'm not putting a tube in this pt b/c its never coming out.

3) What does the stress and echo say? If good this is a standard hip, if not a-line could be a good idea. No sense in delaying because you can't decrease her periop risk by waiting 2 or 3 days so just fix the hip.

Can't delay a urosepsis case. I have a whole new respect for that concept after a friend of mine woke up in the morning with flank pain and was on a vent, xigris, and levophed six hours later.

 

[Idiopathic]

Can't delay a urosepsis case. I have a whole new respect for that concept after a friend of mine woke up in the morning with flank pain and was on a vent, xigris, and levophed six hours later.

you could put them on a vent/xigris/NE without going to the OR

 

[Mman]

you could put them on a vent/xigris/NE without going to the OR

but they'd likely continue to deteriorate farther until the source of infection is dealt with

 

[Idiopathic]

but they'd likely continue to deteriorate farther until the source of infection is dealt with

maybe, i would just argue with the assertion that you cant delay a case because its a decision between ending up in MODS on a vent in the ICU versus a positive outcome by going to the OR. i think you could do a perc drainage rather than decide between GETA and spinal in a clearly unoptimized patient.

 

[Idiopathic]

and whats going to happen to this urosepsis with ureteroscopic manipulation of this stone? it aint gonna get better right away...probably gets worse actually.

 

[ssmallz]

Can't delay a urosepsis case. I have a whole new respect for that concept after a friend of mine woke up in the morning with flank pain and was on a vent, xigris, and levophed six hours later.

If this was a strait urosepsis case I'd agree but this is urosepsis vs PNA. This pt is satting 88-89% of 4L NC. There's likely some residual lung injury from the PNA. Will this pt benefit from a few days of ABx in the ICU to clear up the PNA before we manipulate the stone? Is this stone even septic or it all stemming from the PNA and DKA? I don't know the answer to these questions and that's why we need a pulmonologist of CCU doc to answer it for us. If the pulm guy says "risk of delay > risk of proceeding" then we figure out how to proceed but I'm not going to be the one to make the call in a high risk patient without a cya note from the other service for when things go south.

 

[Mman]

If this was a strait urosepsis case I'd agree but this is urosepsis vs PNA. This pt is satting 88-89% of 4L NC. There's likely some residual lung injury from the PNA. Will this pt benefit from a few days of ABx in the ICU to clear up the PNA before we manipulate the stone? Is this stone even septic or it all stemming from the PNA and DKA? I don't know the answer to these questions and that's why we need a pulmonologist of CCU doc to answer it for us. If the pulm guy says "risk of delay > risk of proceeding" then we figure out how to proceed but I'm not going to be the one to make the call in a high risk patient without a cya note from the other service for when things go south.

I'm pretty sure the pulmonologist or CCU doc is no more capable than you of deciding if the risk of surgery outweighs the risk of delay. What you need is a note from the surgeon documenting the emergent nature of the procedure to CYA. What is the ICU doc going to tell you... the patient has pneumonia and is requiring oxygen and might not be extubatable at the end of the case if done under GA? No kidding.

 

[TrustMe]

you could put them on a vent/xigris/NE without going to the OR

Can't put them on Xigris now. Sorry to play the a-hole. Couldn't resist.

 

[Idiopathic]

Can't put them on Xigris now. Sorry to play the a-hole. Couldn't resist.

BURN!

 

[amyl]

this was from one of my first calls as staff 🙂 1. preop aline and IJ with pressors standing by. surgeon was fast and did a great job so things went just fine. 2. did not want to spinal this guy as he was no way going to tolerate any more fluid. i would have liked to diurese him before but his sepsis was worsening so....he had a ton of pus behind the stone and really did well and turned the corner for the better once it was out. no pent so was prop-sux-tube and all went well. 3. fascia iliaca and LMA, things went great.
i am a huge fascia iliaca fan... just curious... what solution do you guys use for this block? we don't have ropi on formulary here :-( so Im still experimenting

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[pgg]

i am a huge fascia iliaca fan... just curious... what solution do you guys use for this block? we don't have ropi on formulary here :-( so Im still experimenting

I find volume is key with FI blocks. I calc their max LA dose by weight, put that many mg in a 60 cc syringe, dilute to 40 or 50 cc with NS. We have ropivacaine but I'd do the same with bupivacaine. I don't put any additives in the solution.

 

[Oggg]

I do 0.25% bupiv 40-50cc. Lasts 12hours (not as long as a bupiv Paraneural block). I don't see any reason to use ropiv -- you're not near vessels, and you don't care about motor block.

 

[cpants]

With regard to number 2. Febrile pt. with an obstructing stone is a true surgical emergency. Delay for abx, resuscitation, pna treatment is absolutely the wrong answer. Delay for an hour to get lines in and slam a few liters of fluid....sure. More than that, no. If he is too unstable for anesthesia he gets a nephrostomy tube, but decompression must be done STAT. This isn't standard sepsis. These guys don't improve with medical therapy. They get sicker until they die if you don't decompress.

 

[BlackTalon]

Just an intern here.

1. Given the bad heart and possibility of intra-abd sepsis (currently compensated), would a "cardiac induction" be favorable? IJ line, a-line preop. Norepinephrine infusion connected to IJ and ready to go. Induction with high dose fentanyl, thiopentone... Roc and Tube... Maintain with sevo.

2. Would not spinal cos septic and risk of haemodynamic compromise if abscess ruptured intraop. A little concerned abt haemodynamics during induction (again, may be septic but compensating). Preop a-line, good IV. Induction with thiopentone, roc and tube, maintain with sevo.

3. Never seen an IF block done yet. Would a slow induction of epidural analgesia be viable in this case?

 

[Bostonredsox]

1. elderly pt with positive cath (occlusion of rca and lad) but failed angio/stenting and no remaining targets for cabg (they have all been harvested so her cardiologist suggested medical management at her last visit, COPD w FEV1/FVC 30%, PPM/AICD she says was just checked and didn't know what it was placed for. she arrested after her first cabg. also, her family says after her last surgery they messed up her arm (which is totally scarred) because something happened with her heart and they pushed epinephrine (yes they knew) in her IV and it infiltrated -- now for lap possible/probably open exploration for severe abdominal pain with ambigous CT. she is febrile but hemodynamically stable.
-- plan?
2. aged pt admitted w DKA a couple days ago preceeded by pneumonia, moderate COPD, MI in march but echo did not show any WMA. sugars now controlled. saturations on 4L nasal cannula 88-89% showing increased work of breathing, peripheral edema, wheezy lungs. pt is septic and in renal failure, urologist thinks its urosepsis and obstructive uropathy d/t large kidney stone. he is febrile but hemodynamically stable. surgeon says he has to cysto and try and retrieve or push up the stone now despite the pts condition but is okay with a spinal or just an LMA if worried about his condition.
--thoughts?
3. over 90 year old pt w HTN, DM, CAD, COPD, several CVAs, dementia s/p MI 3 weeks ago now for gamma nailing for acute hip fracture?
-- plan?

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#2 is a lot more straight forward than you think. It sounds like she's in the unit with DKA and severe sepsis from probable PNA and a second urologic source. In addition she's satting 88% and has a high level of work of breathing. Still febrile. In a word, she's impending septic shock. If it were me, I would have intubated her, she would already have an IJ and an art in with levophed on standby. All of this would have occurred on arrival to the unit. So when you get the call for GETA and a stone retrieval/stent placement by urology....all you would have to do is roll her to the OR and keep her sedated.

I had this same case about 2 months ago. 65 y/o guy crashing from septic shock with an 18mm UPJ stone. I tubed him, IJ/art, temp sens foley, continuous ScvO2, levophed/vasopressin/dobutamine. Call to the urologist once we picked up the stone. Anesthesia just wheeled him back and said thanks for the lines. Did fine. Except he never weaned I had to trach him. Did go home though. If you had to do all of this crap I mentioned because she was just sitting in MICU breathing on her own with impending septic shock and no lines/pressors, your MICU team dropped the ball. Unless this came to you right from the ED doc.

 

[sevoflurane]

Do you work at Eisenhower? That's the daily grind in Palm Springs.😉

No wonder Somnia is always looking to fill Palm Springs.

Great Tennis community though.

 

[sevoflurane]

Had a patient show up in pre-op last year for emergent Cysto/Stent/litho/basket. Looked like sepsis, smelled like sepsis, was septic.

Lot's of puss... had to pull out some norepi and give a couple of boluses before I dropped her off in the ICU.

Was rounding the next day and the room she was in was empty... 🙁

Urosepsis can, and often does, get worse after a cysto stent + whatever else. They can easily decompensate during the procedure due to massive release of endotoxins. Getting them through the surgery doesn't mean they make it out of the hospital.

 

[Mman]

Had a patient show up in pre-op last year for emergent Cysto/Stent/litho/basket. Looked like sepsis, smelled like sepsis, was septic.

Lot's of puss... had to pull out some norepi and give a couple of boluses before I dropped her off in the ICU.

Was rounding the next day and the room she was in was empty... 🙁

Urosepsis can, and often does, get worse after a cysto stent + whatever else. They can easily decompensate during the procedure due to massive release of endotoxins. Getting them through the surgery doesn't mean they make it out of the hospital.

agreed

But without removal of the source of the infection they are guaranteed to get worse. At least if it is removed they have a chance at overcoming the sepsis.

It's a very bad situation and those can be some of the sickest patients you will ever see. I've had 2 that decompensated so fast postoperatively it was amazing. Walking, talking rolling in through ED and 45 minutes later postop in PACU I had to place CVP and arterial line and start vasopressors and send to MICU from florid vasodilatory shock.

 

[sevoflurane]

agreed

But without removal of the source of the infection they are guaranteed to get worse.

Ohh... yeah... We are eye to eye on this. 👍

Removing the nidus of infection is their best chance. Otherwise, they likely don't have a chance at all.

Sometimes you are fighting an up hill battle from the get go and there is nothing you can do to assure a positive outcome. Somtimes you can snatch them up from the depths of a black hole before they pass the event horizon and reach the singularity.

The ones that you can snatch up, have great upside potential. 🙂

 

[Bostonredsox]

agreed

But without removal of the source of the infection they are guaranteed to get worse. At least if it is removed they have a chance at overcoming the sepsis.

It's a very bad situation and those can be some of the sickest patients you will ever see. I've had 2 that decompensated so fast postoperatively it was amazing. Walking, talking rolling in through ED and 45 minutes later postop in PACU I had to place CVP and arterial line and start vasopressors and send to MICU from florid vasodilatory shock.

This was the point of my post. This is why they get tubed, get their lines and volume PREOP by icu team and have all adjunct therapies ready to roll the moment they come out of the OR. Because at this point i am expecting the postoperative vasodilatory shock, so I am always prepared for it. I would rather take a few min before they go over the cliff to have them ready for when they're free falling on their way back to me.

 

[GoldnLead]

I'm pretty sure the pulmonologist or CCU doc is no more capable than you of deciding if the risk of surgery outweighs the risk of delay. What you need is a note from the surgeon documenting the emergent nature of the procedure to CYA. What is the ICU doc going to tell you... the patient has pneumonia and is requiring oxygen and might not be extubatable at the end of the case if done under GA? No kidding.

Goddamn right. Well said.

As an anesthesiologist, you should be able to walk into any ICU and manage a patient, much less assess a patient's suitability for surgery.

 

[KLPM]

Somtimes you can snatch them up from the depths of a black hole before they pass the event horizon and reach the singularity.

And if you can't? "Sucks" for you? 😛