Really appreciate all the great comments. The case (fortunately) went quite well but you guys have mentioned several things I didn't even give fair consideration when I was thinking about this case.
Had essentially the exact same case last week but with mod pHTN. That is more challenging because it is a dangerous game letting the pCO2 climb/pO2 fall.
Her pulmonary pressures were honestly one of my biggest concerns preoperatively. Even though she had a TTE with estimated PASP in the 30s, the images were quite suboptimal (not surprising given her habitus) and I was concerned that they may have underestimated the PASP based on a poor visualization of the TR jet, esp since I think that method is only decent with good images. She had severe OSA, recent PEs (and was hypercoagulable so who knows if she had reccurent PEs / CTEPH type phenomenon) and LV failure with LAE on echo. I was really worried she had significant undiagnosed pHTN and that even minimal hypoxia on induction could lead us into a bad RV failure scenario. For those of you guys that take care of sick hearts a lot I'm sure my concern was overblown but on my list of things that could send us down the tubes quickly this was high.
Robotic surgery is going to be a terrible idea here and your attending should have a discussion with the surgeon highlighting the issues with steep trendelenburg, long surgery and all the other challenges with this FULLY developed patient.
I think it's interesting that so many people have come out strongly against the robot. These cases are done (thankfully) by our gyn-onc group and they specifically do the robot for these large BMI folks (BMI>50) - apparently it's very challenging if not impossible to do straight stick laparoscopy bc you don't have enough leverage to manipulate the instruments. I don't know if that's true, but that's what I was told. They also try very hard to avoid open approach given a ~30% wound dehissance rate in patients with this BMI from open laparotomy incisions. Fortunately our surgeons are quite good at this with the robot and we were skin-to-skin in ~2.5 hours which is pretty average for our group. We definitely had a discussion preop that she would not tolerate the usual steep T-berg. After induction we tested positioning and settled on 15 degrees of t-berg which is less than they usually request for these cases but I could adequately ventilate her and they had reasonable operating conditions. Her peak pressures after insufflation were in the 45-48 range.
Another major factor here with her positioning is it places her at major risk for nerve injury. The woman I did had bilateral hand weakness due to ulnar nerve compression. It also places the brachial plexus at risk for traction injury if you use those shoulder supports on the bed. You should really discuss this risk preop with both patient and surgeon.
This is a great thought that I didn't really consider very much preop as a CA-1. We use these special "anti-slip" friction pads on the bed for these cases and even in this patient we could do 15 degrees of t-berg without her slipping and no shoulder supports/straps. Fortunately no postop neuropathy issues.
Anyway, here's how it went down. She came down with an infiltrated 20g IV from the floor (typical) and we placed a 22g for induction. We did an awake a-line and then a very stable ketamine/etomidate induction (etomidate was my choice and perhaps unnecessary but eh). Her airway actually looked pretty good, all things considered (MP1, good neck ROM albeit thick neck) and went straight to glide with no issues. RIJ TLC for access. She remained hemodynamically stable throughout. Maintenance was precedex/des/remi - a cocktail my attending (who does a lot of our bari cases) really likes but I haven't used before, not my choice. It worked well though I'm not sure what the precedex was adding on 0.6ish MAC of volatile. We tested positioning prior to any draping or whatnot and gave her 3-4 minutes supine and then 3-4 minutes in 15 deg t-berg to see how she would tolerate it. I hyperventilated her down to a etCO2 of 28-30 prior to insufflation and managed to keep her CO2 fairly well controlled during the case, though I'm sure had it gone long enough I might have run into some problems. Got her breathing and titrated in a whiff of dilaudid to keep her comfortable on emergence. SICU overnight for monitoring. She did very well and went to the floor the next day, then home on POD#4.
A few questions for you guys:
1) For access, would anyone have done this with just u/s guided peripherals given the difficulty of IV access? I've had bad luck with u/s guided IVs infiltrating in patients with this much subcu tissue, I think bc you have so little catheter in the vein - they work for a while but then crap out. Our 22g induction IV had infiltrated by the end of the case but fortunately was just running LR. Losing IVs in tucked arms on a robot on this lady sounded awful.
2) What would you have done for maintenance? The des/remi/precedex combo had a nice wakup, albeit an expensive one.
3) Would you AFOI this patient? I suggested it to my attending because of my concern re: hypoxia and her PA pressures if she turned out to be a difficult airway despite her reassuring exam. He responded that AFOI is to deal with airway issues, not hypoxia issues. Is that how you guys think about fiber optic?
I have to say a very reassuring part of this for me was she had an IVC filter placed the day before (under local) and was able to be supine for the entire ~1h placement which made me feel better about ventilating her.
Thanks again for all the feedback! This is really helpful for those of us still learning.
