Challenging case

[vector2]

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....

I see no reason why the guy wouldn't be pretty easily extubated sitting up wide awake to his 4L NC or worst case scenario to a bit of CPAP while we start some norepi and HD/UF in the ICU. It's not like he's some severe COPDer with FEV1 30- he's fat (which can be attenuated with positioning and CPAP) and he's volume overloaded (which can be fixed with UF). Do the blocks after induction of general and limit opioid and we'll get to a happy place.

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[deleted697127]

So heparin drip is for his critical limb ischemia? Did they turn it off for surgery? How is his airway exam? Any previous intubations?

I wouldn’t want to intubate emergently, if he looks like i could intubate, that’s my plan + femoral awake if it looks easy, asleep if not. Unless i had a reliable second pair of hands managing the vent, pressors, and watching the tube, i don’t think the sciatic is worth the risk/stress of repositioning.

That being said, for all those claiming neuraxial, what do you do if it’s a same day emergent add on? Ask if you can hold heparin and punt it to the next guy? Platelet dysfunction in ESRD patients is also not just theoretical. I don’t know what the risk of epidural hematoma is but i do know that it’s luck if you manage to get a spinal in this guy atraumatically in a single shot.

 

[anbuitachi]

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)

was this the residents plan?

 

[Hork Bajir]

was this the residents plan?

Resident wanted to do straight primary blocks, adding the epidural was at my insistence. My initial thinking was that we might need it just for thigh tourniquet coverage, or to supplement a ****ty block in this generously sized man... Like I said, ended up being very glad that we placed it.

 

[dchz]

he's volume overloaded which can be fixed with Surgical Bleeding

Fixed that for ya. But +1 about NOT worried about extubating him.

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”

This.

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.

This actually brings up a good point. I don't have extensive experience supervising. anyone want to add to this? What happens when you are doing this in a 4:1 coverage?

 

[Hork Bajir]

@dchz I’m relatively junior still so I’m curious to hear the experience of others with respect to supervising. FWIW I’m currently in academics, about 25% of the time working solo, the remainder either working 2:1 with residents or 2-3:1 with CRNAs (very occasional 4:1 at the end of the day when we’re consolidating rooms).

Some of my colleagues are super annoying and will refuse to do any kind of tough case with junior residents while covering another room... Personally, I try to take the whole situation into account. In this case my other room was pretty straightforward and I had a very strong resident who could function pseudo-independently, so I felt fine about the situation. If my other room was also challenging, I would have talked to the desk runner and asked to be 1:1 for however much time is needed (ideally this is worked out the day before, for example if I know I’m going to be doing an open aorta I’ll usually ask to be 1:1 ahead of time). If it’s a request in the heat of the moment- for example if one of my rooms gets into unexpected bleeding and I get too tied up to induce my second room- I can either ask one of my colleagues to temporarily cover my other room while I’m getting caught up, or ask the desk-runner to go 1:1 (which essentially means pulling the resource person).

 

[Arch Guillotti]

Resident wanted to do straight primary blocks, adding the epidural was at my insistence. My initial thinking was that we might need it just for thigh tourniquet coverage, or to supplement a ****ty block in this generously sized man... Like I said, ended up being very glad that we placed it.

Smart move. I know everyone one here places perfect blocks but it was still a wise move.

 

[Arch Guillotti]

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)

Only easier way would have been to do it yourself.

 

[Arch Guillotti]

This actually brings up a good point. I don't have extensive experience supervising. anyone want to add to this? What happens when you are doing this in a 4:1 coverage?

Very tough. Get as caught up as you can and give your phone or beeper to someone else. If they can't handle that then offer to let them take the case.

 

[secretasianman]

This is rock star work. And obviously I’m sure your compensation was commensurate with your level of expertise. Oh wait, medi-cal? Here’s $50

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.

 

[anbuitachi]

This actually brings up a good point. I don't have extensive experience supervising. anyone want to add to this? What happens when you are doing this in a 4:1 coverage?

not a case that should be 4:1 covered. if they hand you this case, talk to the person coordinating.
not a fan of covering crnas. would much rather cover residents. but thats probably a regional/center thing.

 

[Arch Guillotti]

not a case that should be 4:1 covered. if they hand you this case, talk to the person coordinating.

Not always a coordinator. Cases come to your room, you do them. Cases get added on, you do them.

 

[anbuitachi]

Not always a coordinator. Cases come to your room, you do them. Cases get added on, you do them.

yes but at least here we relay these things to coordinator so the coordinator can assign your other 2-3 rooms to someone else to cover while you do this case

 

[vector2]

If you’re in a job that would make you do this case while 4:1 without your colleagues helping out with preop’ing/inducing/temporarily covering your other rooms then you need a new job.

 

[deleted162650]

If you’re in a job that would make you 4:1, then you need a new job.

There, FTFY.

 

[vector2]

There, FTFY.

If only that were feasible for all of us. At least I’m lucky enough I’m only 4:1 toward the end of the day when most rooms are cruising and on their last cases.

 

[deleted162650]

If only that were feasible for all of us.

I know, but sometimes it’s fun to be an MD only snob.

 

[anbuitachi]

I know, but sometimes it’s fun to be an MD only snob.

prefer a mix of low ratio coverage and solo. Solo is kind of boring sometimes sitting in OR all day

 

[IMGASMD]

prefer a mix of low ratio coverage and solo. Solo is kind of boring sometimes sitting in OR all day

Don’t knock on me for warming them benches for nice eyeballs.

 

[joshmir]

Please critique this plan, mostly for academic/learning purposes:

1)bipap, maybe a tiny bit of nitrous if tolerated and if needed
2) some very low dose sedative like 25-50 fentanyl, homeopathic dose of ketamine/precedex that
hat won’t alter hemodynamics-
3) insert touhy into sacral hiatus and thread epidural catheter up to BKA side with tip at L4
4) leave epidural in for postop pain, prevention of phantom limb, reduction of postop tachycardia from pain, reduces CNS and respiratory depression from opiates; run lido or chlorprocaine If really want to be able to turn off quick to check for contralateral LE neurological compromise (but this isn’t really necessary because you can get a stat CT to r/o epidural hematoma.... in a guy who has one leg and likely is always gonna be in a wheelchair.. who will die in a couple years... and it’s very unlikely to happen in a meaningful way if no clinical signs of poor platelet function, with - admittedly 17g touhy but in sacral hiatus)

hell if you aspirate early and often maybe you can suck out the hematoma- just kidding.

preop a line, slow epidural dosing, neo in line, etc

maybe increased risk epidural abscess BC of DM and infected leg ( but now gone); maybe needs heparin gtt postop so u gotta pull catheter; maybe give homeopathic dose of Duramorph for pain control to avoid encephalopathy from systemic opiates supplement with low dose systemic lidocaine and fentanyl postop; If your resident needs a poster presentation to go to ASRA this year anybody wanna try Exparel in his fem/pop blocks? Legs coming off so no harm no foul?

If he’s not making any urine, can he have postop Celebrex when off heparin to help with opiate sparing in the SNF?

please tear apart this plan, presented more for academic dissection than anything else

 

[MirrorTodd]

 

[deleted875186]

Please critique this plan, mostly for academic/learning purposes:

1)bipap, maybe a tiny bit of nitrous if tolerated and if needed
2) some very low dose sedative like 25-50 fentanyl, homeopathic dose of ketamine/precedex that
hat won’t alter hemodynamics-
3) insert touhy into sacral hiatus and thread epidural catheter up to BKA side with tip at L4
4) leave epidural in for postop pain, prevention of phantom limb, reduction of postop tachycardia from pain, reduces CNS and respiratory depression from opiates; run lido or chlorprocaine If really want to be able to turn off quick to check for contralateral LE neurological compromise (but this isn’t really necessary because you can get a stat CT to r/o epidural hematoma.... in a guy who has one leg and likely is always gonna be in a wheelchair.. who will die in a couple years... and it’s very unlikely to happen in a meaningful way if no clinical signs of poor platelet function, with - admittedly 17g touhy but in sacral hiatus)

hell if you aspirate early and often maybe you can suck out the hematoma- just kidding.

preop a line, slow epidural dosing, neo in line, etc

maybe increased risk epidural abscess BC of DM and infected leg ( but now gone); maybe needs heparin gtt postop so u gotta pull catheter; maybe give homeopathic dose of Duramorph for pain control to avoid encephalopathy from systemic opiates supplement with low dose systemic lidocaine and fentanyl postop; If your resident needs a poster presentation to go to ASRA this year anybody wanna try Exparel in his fem/pop blocks? Legs coming off so no harm no foul?

If he’s not making any urine, can he have postop Celebrex when off heparin to help with opiate sparing in the SNF?

please tear apart this plan, presented more for academic dissection than anything else

Wtf, why are we doing a caudal?
Lumbar epidural, or low dose hyperbaric bupi spinal with vasopressors.

Anyone every try a Baer block in the leg? Never heard of it but interested if it might work.

 

[coffeebythelake]

well done positioning an encephalopathic obese patient lateral

There are varying levels of encephalopathy and delirium. If he was combative, thrashing about and uncooperative thats a different story dh? Obviously we heard the conclusion to this case from OP. Pt was cooperative enough to lay lateral and remain still for procedures. How the patient is on paper isn't always how they are when you look at them in person. I'm sure we all know that

 

[coffeebythelake]

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.

Why do a GA with aline, double stick cvc, pa catheter and TEE probe when there is an alternative? Crash cart in room, pads on pt. For a case where regional is not unrealistic option? Would you do a cardiac case for said sick cardiac cripple pafient without it? You also have a CT surgeon who can literally crack the chest if needed and throw the patient on bypass. Sure it's the same bad heart. But it's not the same circumstances and situation.

 

[vector2]

Why do a GA with aline, double stick cvc, pa catheter and TEE probe when there is an alternative? Crash cart in room, pads on pt. For a case where regional is not unrealistic option? Would you do a cardiac case for said sick cardiac cripple pafient without it? You also have a CT surgeon who can literally crack the chest if needed and throw the patient on bypass. Sure it's the same bad heart. But it's not the same circumstances and situation.

I know this past July is only a few months ago but the way 2020 has gone it feels like a necrobump and I barely remember the case in the OP. But looking through the thread briefly, the guy was on heparin and even if that was stopped he was ESRD with some probable platelet dysfunction. He was encephalopathic. He was volume overloaded. He was fat as all f*ck so neuraxial and regional would be a PITA. For me, sedating and regional is an unrealistic option just looking at him on paper. I'm getting some volume off with HD and putting him to sleep with an A-line. Probably don't need swan, TEE if the case isn't too long or too bloody.