Complexity

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jeesapeesa

jeesapeesa

anesthesiologist southern california
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What are considered "complex" cases in anesthesiology? I know that **** can hit the fan in any case, but what kind of cases do attendings/residents consider hardcore as far as pre-op and settings rooms up, morbidity or anything in your guy's opinion? Transplant (liver, hand,etc), Hearts (CABG/transplant), OB, neuro, ortho??
 
Complex: Liver transplant, Heart transplant-although generally these don't go too bad, Lung transplant, Redo-CABG, CABG with poor ventricular function, AAA-especially ruptured, pedi spines-Harrington Rods, NICU baby with NEC, just about anything else sick from the NICU, Craniotomy for aneurysm.

Not Complex: Kidney transplant, hand transplant, Carotids, most big general surgery cases but Whipples can be complex, craniotomy for basic tumors, most ortho stuff.

No real criteria here, just what came to my mind from my experiences so far.
 
I'm doing 3 pediatric open heart cases today (not pda ligations, the real deal). First one is a coarctation with UE pb's of 110/50, tubed, 27week GA, 1000grams, with R->L shunt pda, pfo, asd.

The next one has bt shunts going all over the place and needs some kinda double ventricle outflow thing????????? Whatever.

The last one is a redo-redo mitral valve in a 33kg 5yr old.

Thats complicated...at least to me it is. Can't wait till my hearts month is over now.
 
Id say liver and lung are the 2 hardest ive done... the lung especially is intense.

I didnt find hearts challenging, especially on pump ones.
 
oh, it sucked. big time. two cell saver suckers going full force, and continually filling all four 2 liter containers, for 10.5 out of the 12 hours starts to, well....wear on you.
 
Ive never had 2 cell savers going at the same time.....

Thats unreal!
 
Was it a tough patient or do they just not get enough volume and experience? Most of the livers I have done took 4-6 hours, with one going 10 hours after a misconnected veno-venous bypass cannula shot at least 500 cc's of air into the patient.

Never had to transfuse that much fluid and blood products into a transplant patient.
 
UTSouthwestern said:
Was it a tough patient or do they just not get enough volume and experience? Most of the livers I have done took 4-6 hours, with one going 10 hours after a misconnected veno-venous bypass cannula shot at least 500 cc's of air into the patient.

Never had to transfuse that much fluid and blood products into a transplant patient.
Click to expand...

Its becomming more common place at Rush for some reason. They are experienced liver transplant surgeons but its gettin nasty.

An easy liver for us is an 7-8 hour case with 20 unit product transfused.
 
I'd say liver transplants, lung transplants, thoracoabdominal aortic aneurysms, redo thoracic aortic aneursyms and sick NICU babies top my list.

Ascending aortic aneurysms aren't that difficult once you learn the routine for deep hypothermic circ arrest, but they have a habit of rolling in in the wee hours of the morning and go for hours. EC/IC bypass for Moyamoya isn't that difficult either, just incredibly boring and oftentimes annoying when the surgeon wants the MAP within a 5 point range.
 
Oh yeah, that liver....the dude has a son with MH.

That was fun running a versed drip for 12 hours and bolusing constantly because whatever we gave him had basically one cardiac cycle through the brain until it was sucked out and put in the cell saver.

Anyways the guy is actually on the floors now! Hahaha.
 
What I consider complex:

Liver Transplants
Most Cardiac Cases
Thoracotomies for Lobectomy/Pneumonectomy
Major Vascular Procedures
Major Trauma (especially multi-system)
Some Peds: neonates, congenital heart defects, major craniofacial, etc.
The High-Risk OB patient that needs a surprise C-section
Any time I have to give more than fentanyl and versed to a ASA 4/5 patient
Difficult Airway (If you cannot get the airway, supporting the other organ systems becomes awfully difficult)

I also add a complex modifier to routine cases done by particular surgeons. (Ever done a Laparascopic Abdominal Case where the surgeon insufflates extraperitoneal structures or cuts an iliac vein/artery?)
 
VentdependenT said:
Oh yeah, that liver....the dude has a son with MH.

That was fun running a versed drip for 12 hours and bolusing constantly because whatever we gave him had basically one cardiac cycle through the brain until it was sucked out and put in the cell saver.

Anyways the guy is actually on the floors now! Hahaha.
Click to expand...

Versed metabolism is hepatic with renal excretion. Propofol has shown extrahepatic metabolism during liver transplant. Don't take this the wrong way Venti, I'm just curious since I don't do livers as to why would you use versed?
 
Masseter Spasm said:
I also add a complex modifier to routine cases done by particular surgeons. (Ever done a Laparascopic Abdominal Case where the surgeon insufflates extraperitoneal structures or cuts an iliac vein/artery?)
Click to expand...

No but I did have a surgeon cut right through the Iliac vein in a prone spine case. That one SUCKED big time. Pt survived in spite of the surgeon however.
 
"No but I did have a surgeon cut right through the Iliac vein in a prone spine case. That one SUCKED big time. Pt survived in spite of the surgeon however." --Noyac

I hope it was not an orthopedic surgeon. It is frightening to watch an orthopod attempt to control major vascular bleeding with no hemostasis skills except electrocautery.
 
Noyac said:
Versed metabolism is hepatic with renal excretion. Propofol has shown extrahepatic metabolism during liver transplant. Don't take this the wrong way Venti, I'm just curious since I don't do livers as to why would you use versed?
Click to expand...

What else could I use in a guy with family HX of MH? Certainly cant use nitrous in that case. We were screwed.
 
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