Clinical case

[Direct Laryngoscopy]

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60 yo F with PMHx scleroderma, raynauds, pulmonary HTN (PA systolic in the 90s) admitted with diarrhea, long standing dysphasia scheduled for EGD/PRG-J placement. What's your concerns and plan?

 

[IlDestriero]

I hate pulmonary hypertension patients.

 

[Arch Guillotti]

I hate pulmonary hypertension patients.

Me too. First and foremost would be a realistic talk with the patient and surgeon, preferably at the same time.

 

[Direct Laryngoscopy]

Sorry if I wasn't clear. The PEG-J placement was scheduled by the gastroenterologist in endo.

 

[BuzzPhreed]

You're gonna ride the de-sat train for a long time if you don't keep the systolic above that PA pressure. Maybe off the tracks.

Everything is elective in this patient at this point.

 

[GhostTree]

Clinical concerns for scleroderma and how I'd address them: Short answer, pt gets preinduction aline, and GA with ETT.

Airway- mouth opening likely limited, anticipate a challenging intubation. Consider AFOI if really concerned, modified RSI if not.

GI-clearly this pt has significant dysphagia is at a risk of aspirating into their already crappy lungs. With the diarrhea, the pt is volume down and SBP is going to tank with sedation/induction. Electrolytes are probably altered too. Give some IV volume and replete electrolytes to near normal levels prior to starting.

Pulm- restrictive and fibrotic lungs, with significant pathology evidenced by the severe pHtn. Room air Sats? Recent CXR? Any active pulmonary process that can be addressed prior to going to the OR? As previously mentioned, keep SBP>PASP. Avoid hypoxia/hypercarbia/acidemia...

CV-other than the terrible pulmonary hypertension likely secondary to the lung disease, can have restrictive pericardial disease and conduction abnormalities. What's the baseline activity status? Any recent EKG/echo?

Neuro- sensitive to NMB, no contraindication to sux as far as I know.

Some people may consider doing this case under mac/local but the risk of aspiration coupled with the poor lung function, and the severe pHtn that would only get worse if the pt starts desatting with the scope in, and the possible difficult airway lead me towards a GA.

I'd like to hear other thoughts and how the case went.

 

[BuzzPhreed]

Glycopyrrolate 0.4 mg. Ketamine 25mg. Stick the scope in and get it done. Fast. Anything else is masturbation.

Of course how you'd do it at University of Academia and how I'd do it in Outside Hospital may be vastly different. Not necessarily right or wrong. Just different.

This lady has a death sentence diagnosis. Even if she survives this procedure, we're talking months of life left. At best. This is what others on this forum would call a "no lose" situation.

 

[Planktonmd]

Spray the mouth and the oropharynx with a topical anesthetic, tell her that she might have some discomfort, give 10 mg increments of Propofol until she is a bit sleepy and then tell the GI guy to proceed.
Tell him also to use Lidocaine on the skin.

 

[GhostTree]

Glycopyrrolate 0.4 mg. Ketamine 25mg. Stick the scope in and get it done. Fast. Anything else is masturbation.

Of course how you'd do it at University of Academia and how I'd do it in Outside Hospital may be vastly different. Not necessarily right or wrong. Just different.

This lady has a death sentence diagnosis. Even if she survives this procedure, we're talking months of life left. At best. This is what others on this forum would call a "no lose" situation.

I like it!

This case would probably take ~60-90 minutes where I'm at.

 

[Planktonmd]

I like it!

This case would probably take ~60-90 minutes where I'm at.

If the case is going to take 60-90 minutes then you should refer the patient to a place where it takes only 15 minutes!

 

[Direct Laryngoscopy]

If the case is going to take 60-90 minutes then you should refer the patient to a place where it takes only 15 minutes!

These really take 15 min?

 

[GhostTree]

If the case is going to take 60-90 minutes then you should refer the patient to a place where it takes only 15 minutes!

I'm graduating in a few weeks and moving to a place where things will be faster. It's going to be interesting to see the contrast in practice, and I'll have to adapt.

 

[sevoflurane]

What's the echo show? How are her lungs?
I've bent 20g needles tyring to get through bad scleroderma skin. What's your current access?

Advanced scleroderma affecting multiple organ systems is not joke.

 

[deleted59964]

Glycopyrrolate 0.4 mg. Ketamine 25mg. Stick the scope in and get it done. Fast. Anything else is masturbation.

Any concerns about ketamine and increased PVR?

 

[WholeLottaGame7]

Really? No one? Fine, I'll take one for the team.

Retrograde wire.

 

[BuzzPhreed]

Any concerns about ketamine and increased PVR?

No. Offset by any potential compensatory peripheral vascular resistance. And you're talking low dose here. Just enough for pain control and some dissociative anesthesia in a sick person.

http://www.openanesthesia.org/ABA:Systemic_Effects_of_Ketamine

And it doesn't increase PAP in kids. Corollary should apply but then again kids have far more compliant vessels than a scleroderma patient.

http://www.ncbi.nlm.nih.gov/pubmed/18042853

 

[deleted59964]

Anesth Analg. 2007 Dec;105(6):1578-84, table of contents.
Ketamine does not increase pulmonary vascular resistance in children with pulmonary hypertension undergoing sevoflurane anesthesia and spontaneous ventilation.

yeah - i've read that too - like you say, not sure if it applies here.

miller talks about ketamine increasing pvr more than svr in patients with PHTN ... source for that is something from the 80's though ...
it also says hemodynamic changes are not different b/w 0.5 mg/kg and 1.5mg/kg

i haven't used ketamine in someone with PHTN -- interested to hear from those who have.

 

[Noyac]

Any concerns about ketamine and increased PVR?

No

 

[Noyac]

I deal with PHTN every day.
How do you know you are keeping SBP>PBP without a Swan?
Are you gonna put a swan in this pt?
Are "really" gonna need an A-line in this pt?
Seriously, if you out an A-line in this pt in PP people are gonna really start to question your ability to handle this job.

My plan:
Insure the pt is well topicalized
Insure the pt maintains their own airway and breaths.
Insure the GI guy doesn't dick around.

Next case!

 

[GhostTree]

I deal with PHTN every day.
How do you know you are keeping SBP>PBP without a Swan?
Are you gonna put a swan in this pt?
Are "really" gonna need an A-line in this pt?
Seriously, if you out an A-line in this pt in PP people are gonna really start to question your ability to handle this job.

My plan:
Insure the pt is well topicalized
Insure the pt maintains their own airway and breaths.
Insure the GI guy doesn't dick around.

Next case!

Your points are well taken.

 

[sevoflurane]

While Noy's plan is congruent with most of us here, I think it's important to deleniate the particular organ systems that are affected.

Scleroderma can manifest in many different ways. From difficult intubation from small mouth opening and limited to no neck mobility to a crippled respiratory reserve boardering on respiratory failure. All it takes is a little aspiration to land some of these patients in the ICU. In this particular patient, I would not be suprised to see severe Tricuspid Regurgitation and RV hypertrophy with extremely high right sided pressures- robing the right heart of any luxury perfusion that is present in patients with normal hearts... keeping diastolic pressures high is paramount in this scenario. Right sided heart failure is much harder to treat than LV failure. PA pressures are very high in this patient --->What manuevers are you going to use in order to keep this patient out of danger?

 

[Libertas]

Sorry if I wasn't clear. The PEG-J placement was scheduled by the gastroenterologist in endo.

Nobody has mentioned yet, but this is probably not a case to do off-site.

 

[Direct Laryngoscopy]

Just for some background this a 60 something yo woman who has the above stated history who presented to the hospital with worsening diarrhea, and distention and dysphasia. CT showed a 'High grade SBO'. She also has a Hx of PE and was being anti-coagulated for the last 10 months (heparin gtt was stopped for PEG placement). She actually came from another part of the country to be evaluated and was promptly admitted to the MICU.

PE revealed a 55 Kg deconditioned lady.
Airway exam revealed limited mouth open, no loose teeth somewhat limited neck mobility
SBP 110s/40-50s HR 50-70s
RIJ TLC for access
+ systolic murmur 2/6 left upper border
Lungs clear
Abd distended but NT
Skin taut throughout (so tight that during the procedure, the wire used during the skin perc became uncoiled as the tube was being pulled down into the stomach. GI guys were worried about causing lacerations vs leaving foreign body in the pt)

She had a right heart cath about a year ago which showed RV pressure to be 90/2, PA 95/24

Echo during this admission revealed normal LV function with impaired relaxation, mildly dilated LA, improved RV function from previous echo and moderate pericardial effusion.

PFT: FVC 59% of predicted, FEV1 52% of predicted, FEV1/FVC 70%

This case was scheduled in endo and not the ORs, so if she were to crash and need something like ecmo or RVAD, it would be hike.

Now the case is presented in its entirety, what concerns do you now have and how would you proceed? Would you proceed? The GI fellow said the case would be 'about 30min' which translate into greater than an hour. Would MAC still be an option for some of you guys out there in practice? I'll give what happened a little later.

 

[Noyac]

That does change things a bit.

How long does it take your GI guys to do his procedure?

I would tube someone with a high grade SBO.

 

[GhostTree]

While Noy's plan is congruent with most of us here, I think it's important to deleniate the particular organ systems that are affected.

PA pressures are very high in this patient --->What manuevers are you going to use in order to keep this patient out of danger?

I didn't consider the TR, but I can understand that with the RV hypertrophy/increased wall tension the rt heart is no longer getting as much perfusion as it normally would. Specific maneuvers to increase coronary blood flow would be to prevent tachycardia and any increases in PASP, while keeping up the diastolic pressure. I like vasopressin for increasing DBP without increasing PASP, and inhaled nitric. Low dose epi or milrinone if the RV starts to look like its failing (abrupt change in CVP, desaturation, hypotension). I had an LVAD placement case last week that developed acute Rt heart failure and that's the regimen we used to get through.

Her lung function isn't as bad as I would have expected, but likely some of the pHtn is from the chronic thromboembolic disease.

Just for some background this a 60 something yo woman who has the above stated history who presented to the hospital with worsening diarrhea, and distention and dysphasia.

Now the case is presented in its entirety, what concerns do you now have and how would you proceed? Would you proceed? The GI fellow said the case would be 'about 30min' which translate into greater than an hour. Would MAC still be an option for some of you guys out there in practice? I'll give what happened a little later.

I'm still sticking with my original plan for this pt.

I didn't consider the location but this case should not be done off-site.