Clinical Thread- what's going on here?

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What is going on here and how do you proceed?


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HMMMM, it looks like the abdominal contents may have herniated through the diaphragm into the mediastinum causing the heart to displace L and the R lung to become displaced posteriorly, along with a R pleural effusion. I suppose the space occupying stuff could be a malignancy or an infection/abscess- I see air fluid levels. Crazy stuff whatever it is.

Did you do this case?

Edit: I forgot to touch on how to proceed...

How are his vitals?

If stable, AFOI is a possibility, but seems like RSI with ET tube would be OK, then gastric suction. Hopefully you'd have 2 lg bore IVs by now. Seems like peak pressures would be a concern, not sure what to do about that, keep FiO2 high with smaller TVs I guess. With increased intrathoracic pressures, preload would be decreased. Counteract with fluids and afterload control. What else?
 
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Was this person in an MVC?

Anyway I don't really know much about anesthesia but I do know that he needs that hernia reduced, so he needs to go to the OR.

Overexpanding the opposite lung might compress the great vessels, if they aren't already compressed. Awake intubation with spont. respirations or low-pressure ventilation until the hernia is reduced. That's what my guess would be.
 
Need more background. I agree with what others have said. Appears abdominal contents are up in the thorax. I'd put an NG down before induction. Do RSI. Surgical plan? May need a double lumen tube.
 
HMMMM, it looks like the abdominal contents may have herniated through the diaphragm into the mediastinum causing the heart to displace L and the R lung to become displaced posteriorly, along with a R pleural effusion. I suppose the space occupying stuff could be a malignancy or an infection/abscess- I see air fluid levels. Crazy stuff whatever it is.

Did you do this case?

Edit: I forgot to touch on how to proceed...

How are his vitals?

If stable, AFOI is a possibility, but seems like RSI with ET tube would be OK, then gastric suction. Hopefully you'd have 2 lg bore IVs by now. Seems like peak pressures would be a concern, not sure what to do about that, keep FiO2 high with smaller TVs I guess. With increased intrathoracic pressures, preload would be decreased. Counteract with fluids and afterload control. What else?

Well done bro! Good answer.... but don't jump
to the end. Start with the big picture and work your way to the answer.

Yes I did the case.
 
Is this a baby? Chest looks too round for an adult.
 
Is this a baby? Chest looks too round for an adult.

You are on to something here... but no... an adult in BFE. :eek:

Too much properitoneal fat.
 
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Why is all the action happening on the right? That's strange.
 
http://www.saarcjoa.org/vol1issue1/page94_96.pdf


Here's a paper about a guy with COPD who coughed himself into rupturing the right side of his diaphragm. Rare as hensteeth.

For your case, that would be a possible explanation for his big round thorax.

What's this guy's medical history?
 
History:

60 y/o with RUQ abd pain.

PMH: COPD, pulm htn, CHF, MI, X3 stents, EF 35%, PVD, OSA, + no real care for many years. Last cards visit 5 yrs ago. Illusive history.
Known to have large "hernia" but told that she was "too sick" to do anything about it- outside hospital.
The hernia has been there from the beginning of medical records that are currently available. Patient states that she's "always had something wrong with her lungs"
ATC 02, obese, smoker.

VS:
87% on room air
RR 18
BP 88/65
temp 39 degrees
PVC's

AW:
MP 4
2 FB
Short Neck

Whats the next move and what are you thinking?
 
Awake arterial line prior to induction, send an ABG as well. Obtain 2 large bore IV's, start dripping in some fluids. I'm guessing her hypotension is from the herniated intestines, colon all up in her thorax, but the temperature is concerning. Any possible source for infection. I don't know her HR or WBC, but she looks close to SIRS. Possible hypotension from pending sepsis? Her hypotension is not going to be good for her heart, need to bump up her pressures. She gets an awake intubation, fiber or glide, whichever flavor you choose. Are you going to tell us she is allergic to lidocaine?
 
Awake arterial line prior to induction, send an ABG as well. Obtain 2 large bore IV's, start dripping in some fluids. I'm guessing her hypotension is from the herniated intestines, colon all up in her thorax, but the temperature is concerning. Any possible source for infection. I don't know her HR or WBC, but she looks close to SIRS. Possible hypotension from pending sepsis? Her hypotension is not going to be good for her heart, need to bump up her pressures. She gets an awake intubation, fiber or glide, whichever flavor you choose. Are you going to tell us she is allergic to lidocaine?

Nice... I was hoping for this response.

HR 108
WBC 22k

DLT? Or no?

What r the implications of acute vs chronic hernia of this magnitude?
 
You ever put a DLT in a bad Aw? or how 'bout a DLT in a full stomach?

Hmmm....
 
In peds, I remember that the lungs are messed up from a big congenital diaphragmatic hernia, so you have to be careful not exploding the hypo plastic lung. This could be a similar scenario. Maybe you could do an awake intubation with a ETT. If you need lung separation, use bronchial blocker, low volume/pressures, or intermittent vent, or just have the surgeon push the lung away.
 
I have place a dlt in a difficult airway. Afoi place tube place cook catheter pull tube out then place DLT with glidescope visualization. Its not easy but it worked.
 
In a potentially difficult airway where you may need lung separation I think the options are either DL-->single lumen ETT--> place a bronchial blocker OR DL--> place a single lumen ETT and use an exchange catheter --> DLT --> confirmation with fiberoptic.

I think trying to place a DLT under DL off the bat in a potentially difficult airway/high aspiration risk pt is more risky than either of the above strategies.
 
Who has tried to rail road a 35 fr DLT over a cook exchanger?
 
Is that Colon I see in the lateral? :scared:

I see a full stomach on the chest CT.

Who here is afraid of aspiration?
 
Is that Colon I see in the lateral? Who here is afraid of aspiration?

Hmm is it? I had the same question. I would like to see some higher Thoracic CT slices before I determine how high her aspiration risk is. It may not be as high as it might seem

Who has tried to rail road a 35 fr DLT over a cook exchanger?

:hello:

It can be tricky. Of course, a double lumen tube is unnecessary for this case.

-pod
 
I posted this earlier in the thread. What about an NG before anything, suck out all the goo in her stomach?
 
Is that Colon I see in the lateral? :scared:

I see a full stomach on the chest CT.

Who here is afraid of aspiration?


Looks like colon in the right chest, stomach still looks like it's below the diaphragm at least on the X-ray. We can see all the delicious food she has eaten still in her stomach on the CT. I would not give metoclopramide. I think her aspiration risk is higher, but not from her problem of herniated colon into the chest. If the stomach/LES was up above the diaphragm I'd be more worried.

And this lady has SIRS. Elevated temp at HR >100. Look out for pending sepsis. Any cultures?

I'd start out intubating with a single lumen, and use an exchange catheter if we need to switch to a DLT and take down a lung.
 
You ever put a DLT in a bad Aw? or how 'bout a DLT in a full stomach?

Hmmm....

I've put in both bronchial blockers and DLT in difficult airway.

I actually had an interesting case where the pt had tracheal stenosis and required OLV. I did a AFI with a 6.0, put pt to sleep, then my attending guided a bronchial blocker on the outside of the tube (actually surprised how easy it railroads down), then after it disengaged ET tube, used FO scope to guide to the left main. Apparently this is the way they do it in peds although I never did thoracotomy requiring OLV during my peds rotation. For those that never placed adult BB its important to remember you need a good 4-6 cc in the BB cuff unlike DLT. I learned the hard way that day.

On another ocasion, had a very difficult time placing BB in left main with FO scope. Old school attending walks in tells me to mainstem the left with my tube using FO, then blindly just pass BB, then withdraw only tube. Worked like a charm.

For exchange. AFI with single lumen ET-> pt asleep -> Suction out stomach -> DLT over soft cook with DL used to aid passage. Even for routine cases we do this a lot so the surgeon can do an initial bronchoscopy unless the airway was very easy, then we just reintubate with DL.

Our department threw out all our rigid exchange catheters (yellow ones). We now only carry the soft (green/purple tipped) ones. The rigid ones are very dangerous.
 
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For anyone interested this directly out of miller regarding OLV and difficult airway:

"In patients who require OLV and present with a difficult airway, the primary goal is to establish an airway with an SLT placed orally with the aid of a flexible fiberoptic bronchoscope, after appropriate airway anesthesia is achieved. In selected patients who seem easy to ventilate, this may be performed after induction of anesthesia with a bronchoscope or with a videolaryngoscope.[90] Once the SLT is in place, an independent bronchial blocker can be passed. If the patient requires OLV and cannot be intubated orally, an awake nasotracheal intubation can be performed with an SLT and, once the airway is established, then a bronchial blocker can be passed.

An alternative to achieve OLV in a patient with a difficult airway is to intubate the patient's trachea with an SLT; then a tube-exchange technique can be used to replace the existing SLT for a DLT after general anesthesia is induced. A tube-exchange catheter should have a hollow center channel and universal adapters to insufflate oxygen or be connected to a jet ventilator if necessary. The exchange catheter must be flexible, be long, and have markings on the outer surface to control the depth of insertion while in use. For a DLT the exchange catheter should be at least 83 cm. A 14-Fr exchange catheter can be used for 41-Fr and 39-Fr DLTs; for 37-Fr or 35-Fr DLTs an 11-Fr exchange catheter is used. Specially designed exchange catheters for DLTs are available with a softer distal tip to try to decrease the risk of distal airway trauma (e.g., Cook Exchange Catheter, Cook Critical Care, Bloomington, IN).


The exchange catheter, SLT, and the DLT combination should be tested in vitro before the exchange. A sniffing position facilitates tube exchange. After the exchange catheter is lubricated, it is advanced through an SLT. The catheter should not be inserted deeper than 24 cm at the lips to avoid accidental rupture or laceration of the trachea or bronchi. After cuff deflation, the SLT is withdrawn. Then the endobronchial lumen of the DLT is advanced over the exchange catheter. It is optimal to use a videolaryngoscope during the tube exchange to guide the DLT thorough the glottis under direct vision. If a videolaryngoscope is not available, having an assistant perform standard laryngoscopy during tube exchange partially straightens out the alignment of the oropharynx and glottis and facilitates the exchange. Proper final position of the DLT is then achieved with auscultation and bronchoscopy."
 
On another ocasion, had a very difficult time placing BB in left main with FO scope. Old school attending walks in tells me to mainstem the left with my tube using FO, then blindly just pass BB, then withdraw only tube. Worked like a charm.

That's exactly how I place my left blockers. You can do it in under a minute solo.
 
What is the time course of this ruq pain? Hours, days? More history on pain specifics, please. Would like to have an idea of what we're up against before stumbling ahead.

Do we have a sort of acute on chronic hernia, and is there a perfusion issue with some newly-prolapsed gut? That would be a true now now now emergency.

It occurs to me that the appendix could be hanging out in the ruq. Would be the best presentation of appendicitis ever.
 
What is the time course of this ruq pain? Hours, days? More history on pain specifics, please. Would like to have an idea of what we're up against before stumbling ahead.

Do we have a sort of acute on chronic hernia, and is there a perfusion issue with some newly-prolapsed gut? That would be a true now now now emergency.

It occurs to me that the appendix could be hanging out in the ruq. Would be the best presentation of appendicitis ever.

Dude.... You are skiping ahead..:laugh:

That is exactly where the appendix was. In THE CHEST!

Coolest thing Eva!

You are correct in your thinking: acute on chronic with a lactate of 5.5
 
I posted this earlier in the thread. What about an NG before anything, suck out all the goo in her stomach?

Yes, yes, yes.

Not putting in an NG opens you up for a lawsuit if they aspirate. Well played sir.
 
Why mess with a bronchial blocker. Just main stem a SLT. I have always wondered why we don't do this more often. In fact, one of my partners did that earlier this week and it worked great.

- pod
 
great case, someone better write this up.

and by the way, that advice for placing BB is huge! i struggled with my first one as an attending for 30-40 minutes because i just couldnt get it down the left for whatever reason.
 
Pretty sure that's the foramen in the diaphragm that the esophagus passes through. Or possibly the appendix in this case.

I think it's the foramen between the sternal and costal attachments of the diaphragm. Superior epigastric a. and internal thoracic a. pass through there.
 
Who has tried to rail road a 35 fr DLT over a cook exchanger?

No, but I cringed as I watched another resident do it. IMO, it caused unnecessary trauma. I had intubated the pt with a single lumen for the first part of the case and it wasnt like he had a difficult airway (grade 1 view). Ramming stiff dlt blindly over the exchanger made a bloody mess, large clots had to suctioned out. The pt was also lucky enough to get a cord dilation X2. The scenario went like this:

Tube exchanger passed through slt and slt removed with cuff inflated:eek:

Dlt passed over exchanger and DL attempted. Staff realized this was a right sided tube and sends me out to get a left sided dlt. Pt gets reintubated with slt.

With left dlt in room, exchanger again passed through slt and slt removed for the second time with cuff still inflated:eek:

Then the left dlt was crammed in over the exchanger:confused: Granted she was probably nervous and this may have been her first or second dlt.

I've never used a bronchial blocker but they seem pretty slick. I've placed 6 or 7 dlt's in easy airways without any airway trauma but a bronchial blocker seems like the way to go in a pt with a difficult airway that needs olv.
 
Anyone ever awake FOI passing the DLT straight in over the bronch?

Yes. A few key points when doing this:

(1) Excellent topicalization is necessary
(2) Trim the ends of the DLT (where the connectors go)
(3) Soften the tube by placing it in warm water/saline
(4) One only needs to advance the tube until its in the trachea, then induce and properly position the DLT to allow OLV
 
I think it's the foramen between the sternal and costal attachments of the diaphragm. Superior epigastric a. and internal thoracic a. pass through there.

I've got Grant's, Rohen and Moore, and I can't seem to find this in any of them. What I don't have is a hard internet connection.

What happened to Sevo? There's no snow this time of year...
 
I've done it. Very important to use a 14 french catheter. I insist on the soft tipped (purple end) since I've seen bronchial injuries from the extra-stiff ones. Put it in the endobronchial lumen and go gentle.

Soft-Tip%20Cath.jpg

Hey proman,

Are you sure a 14 fr cook exchanger can go through a 35 fr DLT?
 
Great responses to the scenario guys and gals. :thumbup:

Here are the issues as I see them for this patient with a CDH.

AW: Potentially difficult AW and need or no need for DLT. In this case, the surgeon requested it as there was a ton of abdominal contents in the thorax. However, as POD pointed out, it is NOT absolutely necessary... especially for this case (once we got things back in there proper place we were dealing with an extremely hypoplastic right sided lung! Just like the kiddo's.)

The patient has a full stomach... so decompressing via NG is warranted... but even so, the patient can still aspirate fecal material. Getting a controlled AW is of paramount importance.

The patient is heading towards sepsis. Hypotension/tachycardia/elevated temp and white count. Herniated abdominal contents have now progressed and loops of bowels are strangulated, allowing for ischemia and bacterial translocation.

One thing that comes to mind with this patient, is that they have had abd. contents living in the chest for a long time. Likely, since birth (it's a 3rd world country sometimes out here in the boonies!). As such, they are really living on one lung and have had 2x the flow that the pulm. vascular tree usually sees in healthy patients. Therefore, one doesn't need numbers to know that they are likely going to have superimposed pulmonary hypertension (although I think we are all curious and would have liked to see some pre-op numbers).... So when they go septic, phenylephrine is not the drug of choice here, and avoidence of hypercarbia, pain, hypoxia, etc needs to be part of the anesthetic plan.

Bad heart, poor protoplasm. However, this is an emergency, so we have little to no time to optimize the patient. It's a lung case, so we need to balance fluid intake vs. fluid resuscitation in the setting of a strangulated hernia.

A-line, good access/CVL (one could make an argument for a SGC).

Any particular ventilator modes one would favor here?
 
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