Challenging case

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anbuitachi said:
positioning of this patient for popliteal block would be very challenging. if i can get him prone, i'll do this under block and a blast of ketamine. if not im not going to attempt a pop block supine. too much leg lifting for me.
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I've never done a pop block prone. the lower leg is propped on a mayo stand with blankets or a pillow on it. also not sure I've given anyone ketamine for a block. but, whatever works for ya is what you should do. 👍
 
I ended up placing femoral and sciatic blocks; nerve visualization and needling not too bad despite body habitus (just needed a few nurses to help hold the patient down, since he kept falling asleep and then twitching himself awake). Also placed a lumbar epidural catheter, thinking I was going to need it for thigh tourniquet coverage, and to supplement any holes in the block. Was actually planning no art line, but when the patient vagaled and dropped his BP to 80 during the epidural placement, I decided not to be a hero and placed an art line as well. For IV access, US-guided 10cm arrow catheter into the basilic vein (poor man's midline).

We get into the OR and they go to place a foley... At which point we realize that we can't spread the patient's legs apart at ALL. Not sure if this was from contractures, pelvic arthritis, or what. I had been planning on using the epidural only as a bail-out, but ended up being very glad I placed it because we needed to give 10cc of 2% lido before we could even maneuver the legs apart enough to place a foley and prep. Ran low-dose "peripheral" levo through the midline as we dosed up the epidural, kept the BP train-tracking.

Ultimately patient did fine, got dialyzed the next day and they were actually able to take some volume off, now discharged from the hospital. As many have posted, the quickest and simplest way to do this case would have been a slick GA and a prayer... I'm by no means the world's best regionalist, and despite this post, I don't think heroics to avoid a tube is usually the right answer. But at the end of the day I feel pretty good that I spared this dude a GA.
 
Hork Bajir said:
I ended up placing femoral and sciatic blocks; nerve visualization and needling not too bad despite body habitus (just needed a few nurses to help hold the patient down, since he kept falling asleep and then twitching himself awake). Also placed a lumbar epidural catheter, thinking I was going to need it for thigh tourniquet coverage, and to supplement any holes in the block. Was actually planning no art line, but when the patient vagaled and dropped his BP to 80 during the epidural placement, I decided not to be a hero and placed an art line as well. For IV access, US-guided 10cm arrow catheter into the basilic vein (poor man's midline).

We get into the OR and they go to place a foley... At which point we realize that we can't spread the patient's legs apart at ALL. Not sure if this was from contractures, pelvic arthritis, or what. I had been planning on using the epidural only as a bail-out, but ended up being very glad I placed it because we needed to give 10cc of 2% lido before we could even maneuver the legs apart enough to place a foley and prep. Ran low-dose "peripheral" levo through the midline as we dosed up the epidural, kept the BP train-tracking.

Ultimately patient did fine, got dialyzed the next day and they were actually able to take some volume off, now discharged from the hospital. As many have posted, the quickest and simplest way to do this case would have been a slick GA and a prayer... I'm by no means the world's best regionalist, and despite this post, I don't think heroics to avoid a tube is usually the right answer. But at the end of the day I feel pretty good that I spared this dude a GA.
Click to expand...

Well-done.
If your epidural was also placed on the lateral decub position, you have my absolute respect 🙂
 
Hork Bajir said:
I ended up placing femoral and sciatic blocks; nerve visualization and needling not too bad despite body habitus (just needed a few nurses to help hold the patient down, since he kept falling asleep and then twitching himself awake). Also placed a lumbar epidural catheter, thinking I was going to need it for thigh tourniquet coverage, and to supplement any holes in the block. Was actually planning no art line, but when the patient vagaled and dropped his BP to 80 during the epidural placement, I decided not to be a hero and placed an art line as well. For IV access, US-guided 10cm arrow catheter into the basilic vein (poor man's midline).

We get into the OR and they go to place a foley... At which point we realize that we can't spread the patient's legs apart at ALL. Not sure if this was from contractures, pelvic arthritis, or what. I had been planning on using the epidural only as a bail-out, but ended up being very glad I placed it because we needed to give 10cc of 2% lido before we could even maneuver the legs apart enough to place a foley and prep. Ran low-dose "peripheral" levo through the midline as we dosed up the epidural, kept the BP train-tracking.

Ultimately patient did fine, got dialyzed the next day and they were actually able to take some volume off, now discharged from the hospital. As many have posted, the quickest and simplest way to do this case would have been a slick GA and a prayer... I'm by no means the world's best regionalist, and despite this post, I don't think heroics to avoid a tube is usually the right answer. But at the end of the day I feel pretty good that I spared this dude a GA.
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nice that you were able to position for epidural.
did you do sciatic blocks supine? if so how did you position the patient? i imagine his leg must be like 100 lbs

its probably not contractures limiting the patients legs. i dont think epidural would fix contractures
 
vector2 said:
Did you have to give him any sedation for the blocks or the case?
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50mcg fentanyl for the block, and another 50 during the case.

I’ll confess there was a moment when they were sawing in the saphenous nerve distribution that the patient had some pain- gave 20mg prop and waited about a full minute to see full effect of that dose before telling surgeon to hurry up and buzz through the rest of that part... Other than that, no sedation needed. Patient slept through most of it.
 
@AdmiralChz I respectfully disagree- heparin has been held, and even though UF hasn't been effective, HD has been (normal acid base status, BUN not sky high, no clinical indication of uremic platelet dysfunction). Risk of epidural hematoma is still below the threshold of easy quantification, and probably equivalent to the risk of arrest on induction of GA in this patient (low but not zero).

But even so, fortune favors the bold
 
Hork Bajir said:
@AdmiralChz I respectfully disagree- heparin has been held, and even though UF hasn't been effective, HD has been (normal acid base status, BUN not sky high, no clinical indication of uremic platelet dysfunction). Risk of epidural hematoma is still below the threshold of easy quantification, and probably equivalent to the risk of arrest on induction of GA in this patient (low but not zero).

But even so, fortune favors the bold
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i would argue risk of epidural hematoma is far far below risk of arrest on induction of GA
 
anbuitachi said:
i would argue risk of epidural hematoma is far far below risk of arrest on induction of GA
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I think the risk of a total arrest on GA induction is higher than the risk of devastating epidural hematoma, but I think the risk of either is pretty damn low in absolute terms.

Also keep in mind, therapeutic dosing of unfractionated heparin in an ultra morbidly obese person with ESRD is a pain in the ass, and certainly not a "wait 6 hrs then proceed with hubbed 17g tuohy without coags" case
 
vector2 said:
I think the risk of a total arrest on GA induction is higher than the risk of devastating epidural hematoma, but I think the risk of either is pretty damn low in absolute terms.

Also keep in mind, therapeutic dosing of unfractionated heparin in an ultra morbidly obese person with ESRD is a pain in the ass, and certainly not a "wait 6 hrs then proceed with hubbed 17g tuohy without coags" case
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what is the risk of epidural hematoma in someone anticoagulated with IV heparin?
 
anbuitachi said:
i meant without holding it. as in doing it with someone on heparin drip, ptt 70 or something. do we have any data
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I don’t know anyone who would actually do it. Best bet is to review case reports that are a part of anticoagulation guidelines.
 
Why are people so concerned over platelets & dialysis here doing a spinal?
Sure its a theoretical concern but ASRA just states 'avoid neuraxial in patient with other coagulopathies'

Where is this guy bleeding? Hes already had a TAVI getting 10-15k Heparin.
Epidural hematoma is so rare, why go overboard worrying about these things?

Im mean if he bleeds everytime he brushes his teeth and has epistaxis then yes id avoid a spinal but unless he has a bleeding history then carry on
 
Hork Bajir said:
I ended up placing femoral and sciatic blocks; nerve visualization and needling not too bad despite body habitus (just needed a few nurses to help hold the patient down, since he kept falling asleep and then twitching himself awake). Also placed a lumbar epidural catheter, thinking I was going to need it for thigh tourniquet coverage, and to supplement any holes in the block. Was actually planning no art line, but when the patient vagaled and dropped his BP to 80 during the epidural placement, I decided not to be a hero and placed an art line as well. For IV access, US-guided 10cm arrow catheter into the basilic vein (poor man's midline).

We get into the OR and they go to place a foley... At which point we realize that we can't spread the patient's legs apart at ALL. Not sure if this was from contractures, pelvic arthritis, or what. I had been planning on using the epidural only as a bail-out, but ended up being very glad I placed it because we needed to give 10cc of 2% lido before we could even maneuver the legs apart enough to place a foley and prep. Ran low-dose "peripheral" levo through the midline as we dosed up the epidural, kept the BP train-tracking.

Ultimately patient did fine, got dialyzed the next day and they were actually able to take some volume off, now discharged from the hospital. As many have posted, the quickest and simplest way to do this case would have been a slick GA and a prayer... I'm by no means the world's best regionalist, and despite this post, I don't think heroics to avoid a tube is usually the right answer. But at the end of the day I feel pretty good that I spared this dude a GA.
Click to expand...

How much\often bolus did you dose up the epi to get the adequate level and not tank? Especially since HD response is delayed after a bolus. Never really thought of doing neuraxial on this kind of population due to all the above potential bleeding issues but nice to know others able to push the button successfully. Never had done a spinal before on an AS either lol
 
Newtwo said:
Why are people so concerned over platelets & dialysis here doing a spinal?
Sure its a theoretical concern but ASRA just states 'avoid neuraxial in patient with other coagulopathies'

Where is this guy bleeding? Hes already had a TAVI getting 10-15k Heparin.
Epidural hematoma is so rare, why go overboard worrying about these things?

Im mean if he bleeds everytime he brushes his teeth and has epistaxis then yes id avoid a spinal but unless he has a bleeding history then carry on
Click to expand...


Fair points. Perhaps i'm overtly worried about epidural hematomas.
 
2Fast2Des said:
How much\often bolus did you dose up the epi to get the adequate level and not tank?
Click to expand...

Gave 2-3cc of 2% lido at a time, waiting at least 5-10 minutes between aliquots, prophylactically started Norepi before dosing the epidural. Took about 30 minutes to get an adequate level such that we could spread the legs and start to prep... Surgeon was definitely getting impatient, but I think he also understood how tenuous this patient was and he wasn’t too much of a prick about the extra time it took to load the epidural slowly. Interestingly never needed to go higher than 2 on the Levo

Possible I was overly cavalier with doing a neuraxial? I don’t think so, but I posted the case here to learn from others, so I’m open to the feedback if there’s good evidence to suggest that the risk is higher than I had appreciated
 
Hork Bajir said:
Gave 2-3cc of 2% lido at a time, waiting at least 5-10 minutes between aliquots, prophylactically started Norepi before dosing the epidural. Took about 30 minutes to get an adequate level such that we could spread the legs and start to prep... Surgeon was definitely getting impatient, but I think he also understood how tenuous this patient was and he wasn’t too much of a prick about the extra time it took to load the epidural slowly. Interestingly never needed to go higher than 2 on the Levo

Possible I was overly cavalier with doing a neuraxial? I don’t think so, but I posted the case here to learn from others, so I’m open to the feedback if there’s good evidence to suggest that the risk is higher than I had appreciated
Click to expand...

No you did great all considering. Problem is where I'm at surgeons don't like to wait at all. If any delay to chop chop they get bent out of shape
 
2Fast2Des said:
No you did great all considering. Problem is where I'm at surgeons don't like to wait at all. If any delay to chop chop they get bent out of shape
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I’m not denying that production pressure exists under normal circumstances but i think when patients are obviously train wrecks, a lot of the sense of production pressure is self inflicted. With a 190kg patient, even without the comorbodities this patient has, most surgeons get that you need to slow down and be safe. Don’t let production pressure be the reason you change your assessment of how best to handle sick patients.
 
Newtwo said:
Why are people so concerned over platelets & dialysis here doing a spinal?
Sure its a theoretical concern but ASRA just states 'avoid neuraxial in patient with other coagulopathies'

Where is this guy bleeding? Hes already had a TAVI getting 10-15k Heparin.
Epidural hematoma is so rare, why go overboard worrying about these things?
Click to expand...

It's rare, but if it ends up happening, will they review the case and ask if you had considered platelet dysfunction in the setting of ESRD, etc? "no clinical indication of uremic platelet dysfunction" but would anyone else have ordered any tests to definitively determine clotting ability?

I'm still a newbie, but I feel I wouldn't be able to adequately defend my decision-making if taken to court even though there are clear risks to GA versus regional/neuraxial.
 
Arch Guillotti said:
Very low if it’s been held with normal PTT. A greater concern for me is crappy platelets.
Click to expand...
Agreed. If the PTT is normal do the spinal and move on. Spinal surgery are done all the time on dialysis patient with no problems. I would probably do a low dose isobaric spinal on this guy rather then screwing around with an epidural..
 
axeon123 said:
It's rare, but if it ends up happening, will they review the case and ask if you had considered platelet dysfunction in the setting of ESRD, etc? "no clinical indication of uremic platelet dysfunction" but would anyone else have ordered any tests to definitively determine clotting ability?

I'm still a newbie, but I feel I wouldn't be able to adequately defend my decision-making if taken to court even though there are clear risks to GA versus regional/neuraxial.
Click to expand...
This dude is 190kg with an EF of 25% and valvular pathology. You are far more likely to run into problems with GA then with neuraxial. If someone asks about this then that is the answer you give../.
 
dannyboy1 said:
This dude is 190kg with an EF of 25% and valvular pathology. You are far more likely to run into problems with GA then with neuraxial. If someone asks about this then that is the answer you give../.
Click to expand...

It’s not true in real life but a surgical anesthesia dose spinal in someone with severe AS is a textbook “kill” error


“Central neuraxial analgesia can be used (with extreme caution) in mild cases, but is otherwise to be avoided as it may lead to excessive decreases in SVR and consequently DBP/myocardial perfusion. If used, epidural analgesia is preferable to spinal analgesia.”
www.openanesthesia.org

Aortic Stenosis: Etiology, Pathophysiology, and Clinical Presentation - OpenAnesthesia

www.openanesthesia.org www.openanesthesia.org
 
vector2 said:
It’s not true in real life but a surgical anesthesia dose spinal in someone with severe AS is a textbook “kill” error
Click to expand...

Add PHTN and RV dysfunction to AS and it is a true, in real life kill error...folks keep talking about "Pre-load dependent RV" which means nothing and reflects mid/late 20th century thinking... while never considering RCA flow...
 
I seriously considered an IT catheter for this patient- was very close to pulling the trigger. Don’t think the risk of bleeding is any higher than with an epidural, and a slowly titratable reliable anesthetic is pretty tempting here.

For the trainees reading this- if you’ve never done an (intentional) spinal catheter, find an attending who will let you do it at least once before you finish training. It’s a totally valid technique, and one day it might save your butt in exactly this sort of patient
 
drmwvr said:
Add PHTN and RV dysfunction to AS and it is a true, in real life kill error...folks keep talking about "Pre-load dependent RV" which means nothing and reflects mid/late 20th century thinking... while never considering RCA flow...
Click to expand...
This is a BKA. you don’t exactly need T4 coverage. Low dose isobaric (like 1.4 cc) and a quick surgeon is the way to go. And you are far more likely to get sudden hemodynamic shifts with induction of GA in this patient. you can also do a spinal catheter or an epidural but if you are concerned about bleeding a 25g is much less traumatic then a 17g touhy.
 
dannyboy1 said:
And you are far more likely to get sudden hemodynamic shifts with induction of GA in this patient. you can also do a spinal catheter or an epidural but if you are concerned about bleeding a 25g is much less traumatic then a 17g touhy.
Click to expand...

Nah...statements qualified with "far more likely" in a guy like this are naive...sorry...so are "quick surgeon"...do whatever....GA or PNB...a spinal is asking for trouble tho..needing to predict just where the level ends up in this pt, high or low, is just not necessary.
 
dchz said:
Fair points. Perhaps i'm overtly worried about epidural hematomas.
Click to expand...

i think a lot of people are too worried about epidural hematomas. how many of you had a case of epidural hematoma that required emergency surgery or caused paralysis? epidural hematoma is supposed to be very rare.
 
dannyboy1 said:
This is a BKA. you don’t exactly need T4 coverage. Low dose isobaric (like 1.4 cc) and a quick surgeon is the way to go. And you are far more likely to get sudden hemodynamic shifts with induction of GA in this patient. you can also do a spinal catheter or an epidural but if you are concerned about bleeding a 25g is much less traumatic then a 17g touhy.
Click to expand...

Just to clarify....your plan A is to give this guy 7 mg of bupivacaine single shot spinal and then hope for the best?
 
vector2 said:
Just to clarify....your plan A is to give this guy 7 mg of bupivacaine single shot spinal and then hope for the best?
Click to expand...

I think a 7mg isobaric spinal in this guy would be well tolerated. If that was my plan though, I'd put in an A-line first and have a pressor gtt in-line and probably already going at a low dose.
 
SaltyDog said:
I think a 7mg isobaric spinal in this guy would be well tolerated. If that was my plan though, I'd put in an A-line first and have a pressor gtt in-line and probably already going at a low dose.
Click to expand...

I’m not worried about the hemodynamic instability. I’m worried about the duration for a true BKA plus formalization and possibly the density (assuming we don’t also have the PNBs the OP did). If one thinks general is a bad plan from the get-go for a particular case then having to unexpectedly convert to said general is a hundred times worse.
 
And just to expound on the risks of GA induction, you have centers that do hundreds of inductions yearly on pts coming to the OR for off pump CABG with ICM EF 20%, LVADs, heart tx, lung tx for severe PAH, type A dissections, pericardial windows for tamponade, pulmonary thrombendarterectomies, mediastinal masses, open AAA, and a whole bunch of NORA procedures etc. In most of these places, a sick-as-sht but still non-emergent pt coding during induction when someone who knows what they’re doing is pushing the drugs is a newsmaking event. Having been involved with or having personally performed hundreds of cardiac inductions myself, Including many on some of the sickest pathologies, I can count on one hand the number who actually required some ACLS after the drugs went in. Induction of GA is not really my primary concern in a bad heart when it’s done in a deliberate and prepared fashion— length of surgery, large fluid shifts or blood loss during the surgery, and prolonged hemodynamic instability 2/2 to the surgery (long lift times in OPCAB, long x-clamp times, long pump runs making weaning difficult) are.
 
vector2 said:
I’m not worried about the hemodynamic instability. I’m worried about the duration for a true BKA plus formalization and possibly the density (assuming we don’t also have the PNBs the OP did). If one thinks general is a bad plan from the get-go for a particular case then having to unexpectedly convert to said general is a hundred times worse.
Click to expand...

I do multiple TKA's and THA's every week using 7.5mg isobaric bupi (plain, no opioid). I get 3+ hours. I'd feel very confidant with that dose for this guy getting a BKA.
 
SaltyDog said:
I do multiple TKA's and THA's every week using 7.5mg isobaric bupi (plain, no opioid). I get 3+ hours. I'd feel very confidant with that dose for this guy getting a BKA.
Click to expand...

I’ll be the first to admit I had no idea a bunch of ppl were doing these kind of doses for hips and knees let alone getting that duration. I’ve never really deviated from 2+ cc of isobaric for ortho
 
vector2 said:
And just to expound on the risks of GA induction, you have centers that do hundreds of inductions yearly on pts coming to the OR for off pump CABG with ICM EF 20%, LVADs, heart tx, lung tx for severe PAH, type A dissections, pericardial windows for tamponade, pulmonary thrombendarterectomies, mediastinal masses, open AAA, and a whole bunch of NORA procedures etc. In most of these places, a sick-as-sht but still non-emergent pt coding during induction when someone who knows what they’re doing is pushing the drugs is a newsmaking event. Having been involved with or having personally performed hundreds of cardiac inductions myself, Including many on some of the sickest pathologies, I can count on one hand the number who actually required some ACLS after the drugs went in. Induction of GA is not really my primary concern in a bad heart when it’s done in a deliberate and prepared fashion— length of surgery, large fluid shifts or blood loss during the surgery, and prolonged hemodynamic instability 2/2 to the surgery (long lift times in OPCAB, long x-clamp times, long pump runs making weaning difficult) are.
Click to expand...

Yes but that's a low N compared to the # of epidural/spinals you need to do to get a significant epidural hematoma.
Also it may be center dependent but i was a resident at a self proclaimed heart center and most of the cardiac patients are not nearly as sick. most of them have isolated cardiac pathologies. the off pump CABG may have left main stenosis and another vessel or 2. the valve repairs may have AS or AR or another valvular issue. but more often than not do not also have EF of 20% + severe AS + pHTN + ESRD + super morbid obesity. Plus this case probably does not have a bypass machine on standby...
 
anbuitachi said:
Yes but that's a low N compared to the # of epidural/spinals you need to do to get a significant epidural hematoma.
Also it may be center dependent but i was a resident at a self proclaimed heart center and most of the cardiac patients are not nearly as sick. most of them have isolated cardiac pathologies. the off pump CABG may have left main stenosis and another vessel or 2. the valve repairs may have AS or AR or another valvular issue. but more often than not do not also have EF of 20% + severe AS + pHTN + ESRD + super morbid obesity. Plus this case probably does not have a bypass machine on standby...
Click to expand...

Epidural hematoma also isn’t the only risk involved with doing neuraxial on this guy. And beyond the other mechanical and hemodynamic complications of neuraxial (whose risk is surely an order of magnitude or two higher with this pt than the general population rates quoted in the literature), I still maintain you are taking on a much bigger risk if you end up having to (god forbid) deeply sedate this guy sans protected airway to allow him to tolerate the positioning or procedure duration. Clearly the OP with eyes on the pt saw he was going to be able to do so with a whiff of fentanyl, but I wasn’t optimistic reading the description of “encephalopathic + doesn’t like lying flat”
 
vector2 said:
And just to expound on the risks of GA induction, you have centers that do hundreds of inductions yearly on pts coming to the OR for off pump CABG with ICM EF 20%, LVADs, heart tx, lung tx for severe PAH, type A dissections, pericardial windows for tamponade, pulmonary thrombendarterectomies, mediastinal masses, open AAA, and a whole bunch of NORA procedures etc. In most of these places, a sick-as-sht but still non-emergent pt coding during induction when someone who knows what they’re doing is pushing the drugs is a newsmaking event. Having been involved with or having personally performed hundreds of cardiac inductions myself, Including many on some of the sickest pathologies, I can count on one hand the number who actually required some ACLS after the drugs went in. Induction of GA is not really my primary concern in a bad heart when it’s done in a deliberate and prepared fashion— length of surgery, large fluid shifts or blood loss during the surgery, and prolonged hemodynamic instability 2/2 to the surgery (long lift times in OPCAB, long x-clamp times, long pump runs making weaning difficult) are.
Click to expand...
Not worried about intubating him. But extubation will be a problem. You should avoid the option that will likely lead to an ICU stay and prolonged MV if possible....
 
Ronin786 said:
Did you do this case solo or with a CRNA? And if not, would you guys do anything differently if you were running two rooms.
Click to expand...

Did it with a resident. Was also covering a second resident doing a crani across the hall (second room was with a CA3 close to graduating, young healthy patient)
 
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