Chiari Type 1

[kmurp]

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Any experience or opinions on SAB with Chiari Type 1? It’s an outpatient procedure and due to limited PPE, we are trying to avoid GA as much as possible. I don’t have a recent MRI.

 

[vector2]

Any experience or opinions on SAB with Chiari Type 1? It’s an outpatient procedure and due to limited PPE, we are trying to avoid GA as much as possible. I don’t have a recent MRI.

Repaired? Unrepaired? Coexisting syringomyelia? Symptomatic? What procedure? Are they followed by neurology and/or nsgy?

"I dont have an MRI, can I proceed" doesnt usually cut it for these pts...

 

[kmurp]

All I have access to is a brief H&P that mentions Chiari Type 1. The surgeries mentioned in the H&P do not include any neurosurgery, just some knee scopes (which she’s scheduled for tomorrow). That’s all I know until I meet her tomorrow.

 

[dipriMAN]

I think if it’s an outpatient procedure, any risk associated with SAB will be unacceptable, just do GA.

Are you testing all surgical patients?

 

[Guillemot]

Chiari 1 has heterogeneity presentation and anatomical pathology. Many Chiari type 1 are asymptomatic and discovered incidentally on imaging done for another reason. On the other end of the spectrum is hydrocephalus, cranial nerve deficits, and cerebellar deficits, as well as neurological deficits related to syringomyelia. Apparently Chiari malformations can also be associated with Klippel-Fiel Anomaly which can result in an unstable cervical spine.

It would probably be fine to do a spinal in some circumstances and not in others. If you don't have the information needed to make the determination, then you can just do GA.

So I guess it depends. I'm not an expert by any means. I just read about the disease a while ago and figured I'd share what I remembered.

 

[kmurp]

Thanks all for your prompt replies. I think that the advice to avoid SAB given the paucity of other information on her sounds wise. Hope she doesn‘t look like a Klippel-Fiel.....
Also in answer to the question above regarding testing (assume this means Covid), yes we are testing all but having a bit of trouble with the timing with some. Also Monday mornings are difficult if the testing was done over the weekend; it’s hard to get the results for the 7:30 cases.

 

[MirrorTodd]

Could you just do an epidural and pretend it's a c-section? I know that's outside the realm of outpt procedures, but just tell the surgeon to work fast and don't puncture the dura.

 

[DocMcCoy]

Doing something you are uncomfortable with vs one case worth of PPE? No brainer to me. If they can’t afford a case worth of PPE or don’t agree with your reasoning, they probably shouldn’t be doing elective at all.

 

[deleted162650]

Who the f*** does an SAB for an outpt knee scope???

Put the LMA in and get back to Sudoku.

 

[kmurp]

Could you just do an epidural and pretend it's a c-section? I know that's outside the realm of outpt procedures, but just tell the surgeon to work fast and don't puncture the dura.

A wet tap with a touhy could be very bad in this case. So I’m not keen to try that. We do many of our outpatient knee scopes with nesacaine spinals or epidurals normally. They work well, with occasional epidural failures (one sided block) and occasional outliers on motor recovery.

 

[JiPo]

How about Lma and single shot adductor canal post-induction? It would give patient great analgesia post-op and it is easy to do.

 

[DocVapor]

Who the f*** does an SAB for an outpt knee scope???

Put the LMA in and get back to Sudoku.

There's still plenty of places who are doing ETT or spinal, no LMA due to COVID-19. And don't trust a negative test. I'm currently on mandatory quarantine thanks to a patient with 2 negative tests over the course of several days turning positive 2 days after surgery.

 

[Southpaw]

Who the f*** does an SAB for an outpt knee scope???

Put the LMA in and get back to Sudoku.

did a lot of SAB for knee scopes in my old job. Surgeons liked it Bc they could show patients all their arthritis, use that time to talk w them, and schedule the arthroplasty post op.

 

[Southpaw]

For the case as described, if you’re concerned about covid19 (high prevalence area) I’d do GETA +/- ACB.

 

[ragnathor]

If Chiari I not symptomatic or mild, OB literature generally supports SAB or epidural. No case reports of adverse outcomes.

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[IMGASMD]

If don’t want to do LMA.... RSI with a tent/box to minimize aerosol spread. Even if the patient had a negative test. N95 for every case now. Up to you for the rest. I don’t even see patient without one, positive or negative test results.
We had one patient who was positive in the beginning of April, came in last week, still positive.

I’d protect foremost, myself, patient, sadly to say, lastly staff. If the hospital/surgicenter can not obtain adequate protection for their staff and still want to open for business, quite frankly it’s on them. Certainly we have something to say, and I would say it strongly. At end of the day I can only do what I can do to protect myself and my family.

/end rant

 

[KENY1]

Intubation box..in most cases it's taken off after intubation and so the aerosol inside it flies everywhere..correct ? A plastic drape with strong suction under it that stays on throughout the case and recovery seems safer to me..
This question whether an LMA or an ETT is better in a potential C 19+ - if the LMA is smooth with an apneic patient on induction, well suctioned on extubation and not needing positive pressure it's likely ok and maybe better than an ETT but how will u make sure all those will happen ?
Btw: adductor block after GA...kinda breaks the rule blocks should be done awake unless not possible like in kids, correct ..?

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[MirrorTodd]

Intubation box..in most cases it's taken off after intubation and so the aerosol inside it flies everywhere..correct ? A plastic drape with strong suction under it that stays on throughout the case and recovery seems safer to me..
This question whether an LMA or an ETT is better in a potential C 19+ - if the LMA is smooth with an apneic patient on induction, well suctioned on extubation and not needing positive pressure it's likely ok and maybe better than an ETT but how will u make sure all those will happen ?
Btw: adductor block after GA...kinda breaks the rule blocks should be done awake unless not possible like in kids, correct ..?

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Where is that rule from?

 

[deleted171991]

Where is that rule from?

Malpractice lawyer's handbook.

 

[MirrorTodd]

Malpractice lawyer's handbook.

God damn lawyers.

 

[deleted162650]

Btw: adductor block after GA...kinda breaks the rule blocks should be done awake unless not possible like in kids, correct ..?

Im fine with ACB asleep or after SAB since there’s no motor component.

 

[Arch Guillotti]

Im fine with ACB asleep or after SAB since there’s no motor component.

Same here.

 

[narcotics999]

Knee scope? Lma or local by surgeon + propofol gtt.


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