Cool Case Today

[jetproppilot]

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Well, as cool as a case can be when you're on weekend call..

25 y/o healthy female, 30 weeks gestation, with suspected acute appendicitis. Going to the OR for an open appendectomy.

No allergies, no meds except prenatal vitamins, blah blah blah.

You're a CA-2, on call on Sunday, and your attending was just rushed to the cath-lab with a totally occluded RCA. Numerous phone calls to other staff reveal answering machines only.

Its all you now.

Walk us through the case.

 

[DrDre']

Hey Jet,

Lowly piss ant rapper here.


How 'bout supratentorial lidocaine infusion, spont. breathing, versed and the Chronic for sedation-mood music?


Seriously:

GA with premed citrate, reglan d/t pregnancy, decreased eso spincter tone, gravid uterus, delayed gastric emptying in pregos.

Oral endotracheal tube, attn to traumatic view d/t increased risk of rapidly evolving mucosal edema in pregos. Tube rather than LMA d/t above issues.

Little to no subq caines d/t fetal toxicity risk?

Low mac inhaled with some versed and opioids.

OK, don't laugh. I am bored between writin rhymes, and it has been a long time since i have been in the OR!

Well, as cool as a case can be when you're on weekend call..

25 y/o healthy female, 30 weeks gestation, with suspected acute appendicitis. Going to the OR for an open appendectomy.

No allergies, no meds except prenatal vitamins, blah blah blah.

You're a CA-2, on call on Sunday, and your attending was just rushed to the cath-lab with a totally occluded RCA. Numerous phone calls to other staff reveal answering machines only.

Its all you now.

Walk us through the case.

 

[MAC10]

Well, as cool as a case can be when you're on weekend call..

25 y/o healthy female, 30 weeks gestation, with suspected acute appendicitis. Going to the OR for an open appendectomy.

No allergies, no meds except prenatal vitamins, blah blah blah.

You're a CA-2, on call on Sunday, and your attending was just rushed to the cath-lab with a totally occluded RCA. Numerous phone calls to other staff reveal answering machines only.

Its all you now.

Walk us through the case.

Just a CA-1 but ill take a stab. Had this very senierio a month ago.

My plan would be spinal, mabey CSE if she is obese, previous abd sx, slow surgeon. Prehydrate. Get her back to the OR. Place monitors. Place spinal or CSE. For spinal .75% Marcaine, fentanyl or sufenta, and epi combo seemed to work well. Left uterine tilt and a syringe a Ephedrine handy. Little to nothing in terms of sedation, mabey a touch of fentanyl or ketamine.

 

[Monty Python]

Just a CA-1 but ill take a stab. Had this very senierio a month ago.

My plan would be spinal, mabey CSE if she is obese, previous abd sx, slow surgeon. Prehydrate. Get her back to the OR. Place monitors. Place spinal or CSE. For spinal .75% Marcaine, fentanyl or sufenta, and epi combo seemed to work well. Left uterine tilt and a syringe a Ephedrine handy. Little to nothing in terms of sedation, mabey a touch of fentanyl or ketamine.

GETA with RSI and smaller ETT after pre-treatment, versed OK if indicated since past first trimester, no N20, FHT monitor on, OB and peds informed and perhaps in route (his/her decision), LUD position.

 

[seattledoc]

I'd go the spinal route. Bupivicaine, fentanyl, duramorph. No sedation, except Miles Davis "Kind of Blue"

 

[davvid2700]

I'd go the spinal route. Bupivicaine, fentanyl, duramorph. No sedation, except Miles Davis "Kind of Blue"

I would go the spinal route as well.. If they can do a c section under spinal they sure as hell can do an appy.

I would use John coltrane instead of miles for sedation. You dont want the baby to come out to be a sociopath.

 

[VentdependenT]

Just a CA-1 but ill take a stab. Had this very senierio a month ago.

My plan would be spinal, mabey CSE if she is obese, previous abd sx, slow surgeon. Prehydrate. Get her back to the OR. Place monitors. Place spinal or CSE. For spinal .75% Marcaine, fentanyl or sufenta, and epi combo seemed to work well. Left uterine tilt and a syringe a Ephedrine handy. Little to nothing in terms of sedation, mabey a touch of fentanyl or ketamine.

Sounds spot on if she doesn't pass out. I'd be worried about aspiration in someone > 12 weeks (I think?) pregnant. The possible acute abdomen doesn't make me too keen on an unprotected airway in case something wicked happens.

I'm thinking general in my piddley ca-uno mind (no ob for me yet).

 

[supahfresh]

I agree. nobody at our institution would do anything but a GETA. 1 mg/kg propofol, RSI. They should do it open. Have an ultrasound there too.

 

[Idiopathic]

I'd go the spinal route. Bupivicaine, fentanyl, duramorph. No sedation, except Miles Davis "Kind of Blue"

Exactly my thoughts. Less traumatic than a caesarean, anesthesia can be done the same.

 

[jetproppilot]

Well, as cool as a case can be when you're on weekend call..

25 y/o healthy female, 30 weeks gestation, with suspected acute appendicitis. Going to the OR for an open appendectomy.

No allergies, no meds except prenatal vitamins, blah blah blah.

You're a CA-2, on call on Sunday, and your attending was just rushed to the cath-lab with a totally occluded RCA. Numerous phone calls to other staff reveal answering machines only.

Its all you now.

Walk us through the case.

Nice responses! I'll post later when I get to work (got the night duty this week..yuk) how we did the case.

 

[jwk]

Well, as cool as a case can be when you're on weekend call..

25 y/o healthy female, 30 weeks gestation, with suspected acute appendicitis. Going to the OR for an open appendectomy.

No allergies, no meds except prenatal vitamins, blah blah blah.

You're a CA-2, on call on Sunday, and your attending was just rushed to the cath-lab with a totally occluded RCA. Numerous phone calls to other staff reveal answering machines only.

Its all you now.

Walk us through the case.

With fast surgeon and willing patient: Epidural (SAB OK but we do so many epidurals we wouldn't do one), tilt left, fentanyl or versed fine for sedation.

Slower surgeon and unwilling patient: GA with RSI (of course no LMA, that wouldn't enter my mind) tilt left, usual size ETT (why smaller?), N2O not a problem.

On either one - Bicitra, FHT's checked before and after but intraop not practical or needed, OB probably notified as a courtesy (in-house anyway), peds doesn't matter (NICU also in house but won't be needed).

We do these cases fairly often, might even do it laparoscopically. We do a fair number of late 2nd / early 3rd trimester lap choles.

 

[Noyac]

I agree with all. Type of anesthetic is of little consequence. Must protect airway and monitor FHT's as mentioned. If you choose spinal, I have no problem with sedation however, I like the propofol/ketamine type best. When I give propofol, it is in tiny doses and never to unconsciousness in this pt. population. If I give ketamine, I use versed as well.

 

[jetproppilot]

Well, as cool as a case can be when you're on weekend call..

25 y/o healthy female, 30 weeks gestation, with suspected acute appendicitis. Going to the OR for an open appendectomy.

No allergies, no meds except prenatal vitamins, blah blah blah.

You're a CA-2, on call on Sunday, and your attending was just rushed to the cath-lab with a totally occluded RCA. Numerous phone calls to other staff reveal answering machines only.

Its all you now.

Walk us through the case.

I agree with Noy...you can do this case a variety of ways.

Chose a CSE since the surgeon is known to be slow.

She was pretty buzzed on phenergan when she got to us so didnt give any sedation for placement...17" Tuohy, 26" spinal needle, 12mg hyperbaric bupiv (I usually give it all but she was tiny), catheter in, needle out, tape. Towards the end (surgeon dude called in an OB to check something out so the case took longer than it should have) gave 5ml 2% lido with epi. Ran a propofol infusion to keep her just a little sleepy.

Concerning a GA, I've yet to do a GA on a parturient that I couldnt get a 7.0 tube in..I know that "upper airway edema" is emphasized in residency (hence you should use a smaller tube), but I've never seen it.

Venty, you're right..you worry about aspiration...but IMHO the fear you receive in residency about it is overblown. You can comfortably do an RSI with a 7.0 and still have a heart rate (your heart rate) BELOW 70. And I also think the importance linked to the Selleck maneuver is also overblown.

The only part of the case you guys screwed up about the case was the music emanating from surgeon-dude's ipod setup, selected by yours truly:

LINKIN PARK, meteora.

Nice thread.

 

[DrDre']

I know you too well, Jet!

I knew you were going to say it wasn't a big deal about aspiration risk!! 🙂

good thread.

I agree with Noy...you can do this case a variety of ways.

Chose a CSE since the surgeon is known to be slow.

She was pretty buzzed on phenergan when she got to us so didnt give any sedation for placement...17" Tuohy, 26" spinal needle, 12mg hyperbaric bupiv (I usually give it all but she was tiny), catheter in, needle out, tape. Towards the end (surgeon dude called in an OB to check something out so the case took longer than it should have) gave 5ml 2% lido with epi. Ran a propofol infusion to keep her just a little sleepy.

Concerning a GA, I've yet to do a GA on a parturient that I couldnt get a 7.0 tube in..I know that "upper airway edema" is emphasized in residency (hence you should use a smaller tube), but I've never seen it.

Venty, you're right..you worry about aspiration...but IMHO the fear you receive in residency about it is overblown. You can comfortably do an RSI with a 7.0 and still have a heart rate (your heart rate) BELOW 70. And I also think the importance linked to the Selleck maneuver is also overblown.

The only part of the case you guys screwed up about the case was the music emanating from surgeon-dude's ipod setup, selected by yours truly:

LINKIN PARK, meteora.

Nice thread.

 

[jetproppilot]

I know you too well, Jet!

I knew you were going to say it wasn't a big deal about aspiration risk!! 🙂

good thread.

Not that its not a big deal, O.G.. it is a risk, and as you know, 3rd trimester women are considered full stomachs..i.e. asking them when they ate last is kinda irrelevant in my opinion..I'm gonna treat her like she ate a whopper an hour ago anyway....next to NPO status I write FS, regardless of when she ate last.

Its just that, secondary to training in residency, you emerge with these mortal fears about putting a pregnant woman to sleep concerning aspiration and not being able to use a normal size tube, and because of said training, you emerge paranoid.

No paranoia needed. Concern, yes. Paranoia, no.

I think residency training has failed somewhat in this area and other areas...yes, train a resident for worst case scenerios, let them know this is a risk and the patient needs to be treated accordingly, but let them know aspiration risk is VERY low and the chance you wont be able to use a 7.0-7.5 tube is EVEN LOWER.

 

[DrDre']

Nice to hear from the "other side!" Thx as always. I'm goin to the Compton swap meet today, my VCR crashed. Need anything while I am there?

Not that its not a big deal, O.G.. it is a risk, and as you know, 3rd trimester women are considered full stomachs..i.e. asking them when they ate last is kinda irrelevant in my opinion..I'm gonna treat her like she ate a whopper an hour ago anyway....next to NPO status I write FS, regardless of when she ate last.

Its just that, secondary to training in residency, you emerge with these mortal fears about putting a pregnant woman to sleep concerning aspiration and not being able to use a normal size tube, and because of said training, you emerge paranoid.

No paranoia needed. Concern, yes. Paranoia, no.

I think residency training has failed somewhat in this area and other areas...yes, train a resident for worst case scenerios, let them know this is a risk and the patient needs to be treated accordingly, but let them know aspiration risk is VERY low and the chance you wont be able to use a 7.0-7.5 tube is EVEN LOWER.

 

[jetproppilot]

Nice to hear from the "other side!" Thx as always. I'm goin to the Compton swap meet today, my VCR crashed. Need anything while I am there?

Yeah, pick me up KORNs new CD!

Ahh, never mind. Gangstas aint gonna have it.

 

[Noyac]

She was pretty buzzed on phenergan when she got to us so didnt give any sedation for placement...17" Tuohy, 26" spinal needle, 12mg hyperbaric bupiv (I usually give it all but she was tiny), catheter in, needle out, tape. Towards the end (surgeon dude called in an OB to check something out so the case took longer than it should have) gave 5ml 2% lido with epi. Ran a propofol infusion to keep her just a little sleepy.

Concerning a GA, I've yet to do a GA on a parturient that I couldnt get a 7.0 tube in..I know that "upper airway edema" is emphasized in residency (hence you should use a smaller tube), but I've never seen it.

Yeah, I hate that phenergan ****. They always come to the OR with 25mg phenergan given in the ER and it makes them a bitch to wake up. Now I gotta withhold some narcs just so she will wakeup. anyway, I wanted to compliment you, Jet, on your spinals in general. I almost always give the the whole 2 cc as well except when they are really small. Some of my partners think I am a cowboy in that regard but I hardly ever have them vomit during externalization of the uterus in cesereans. I have never seen a total spinal with bupiv. 15mg. I know, maybe I haven't done enough. I do see their small fingers start to get numb from time to time. 👍
I also agree with your ETT size. Most of the edema we see comes in the last few weeks of gestation and mostly with pre-eclamptics.

 

[Noyac]

She was pretty buzzed on phenergan when she got to us so didnt give any sedation for placement...17" Tuohy, 26" spinal needle, 12mg hyperbaric bupiv (I usually give it all but she was tiny), catheter in, needle out, tape. Towards the end (surgeon dude called in an OB to check something out so the case took longer than it should have) gave 5ml 2% lido with epi. Ran a propofol infusion to keep her just a little sleepy.

Concerning a GA, I've yet to do a GA on a parturient that I couldnt get a 7.0 tube in..I know that "upper airway edema" is emphasized in residency (hence you should use a smaller tube), but I've never seen it.
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Yeah, I hate that phenergan ****. They always come to the OR with 25mg phenergan given in the ER and it makes them a bitch to wake up. Now I gotta withhold some narcs just so she will wakeup. anyway, I wanted to compliment you, Jet, on your spinals in general. I almost always give the the whole 2 cc as well except when they are really small. Some of my partners think I am a cowboy in that regard but I hardly ever have them vomit during externalization of the uterus in cesereans. I have never seen a total spinal with bupiv. 15mg. I know, maybe I haven't done enough. I do see their small fingers start to get numb from time to time. 👍
I also agree with your ETT size. Most of the edema we see comes in the last few weeks of gestation and mostly with pre-eclamptics.

Just curious, did you monitor FHT"s?

 

[jetproppilot]

She was pretty buzzed on phenergan when she got to us so didnt give any sedation for placement...17" Tuohy, 26" spinal needle, 12mg hyperbaric bupiv (I usually give it all but she was tiny), catheter in, needle out, tape. Towards the end (surgeon dude called in an OB to check something out so the case took longer than it should have) gave 5ml 2% lido with epi. Ran a propofol infusion to keep her just a little sleepy.

Concerning a GA, I've yet to do a GA on a parturient that I couldnt get a 7.0 tube in..I know that "upper airway edema" is emphasized in residency (hence you should use a smaller tube), but I've never seen it.
--------------------------------------------------------------------------
Yeah, I hate that phenergan ****. They always come to the OR with 25mg phenergan given in the ER and it makes them a bitch to wake up. Now I gotta withhold some narcs just so she will wakeup. anyway, I wanted to compliment you, Jet, on your spinals in general. I almost always give the the whole 2 cc as well except when they are really small. Some of my partners think I am a cowboy in that regard but I hardly ever have them vomit during externalization of the uterus in cesereans. I have never seen a total spinal with bupiv. 15mg. I know, maybe I haven't done enough. I do see their small fingers start to get numb from time to time. 👍
I also agree with your ETT size. Most of the edema we see comes in the last few weeks of gestation and mostly with pre-eclamptics.

Just curious, did you monitor FHT"s?

Nope. I've yet to see that done. I dont think its done very much.

JWK, do you guys monitor FHTs intraop?

Actually we had a better FHT monitor...the baby kept kicking John the surgeon's hand throughout the whole procedure.

 

[VentdependenT]

If she is awake with minimal sedation and blows a preternatural geyser of bile out her mouth, but can cough/gag/respond coherently (ie can protect her airway), would you then proceed to intubation? Or do you suction and wait for the dry heaves?

Lez say the pt is pain free from the CSE and the sats are steady. Presumably the n/v is from the surgeon pullen on the vicera.

Lez say your I-POD fries and all you have left is the eight track in the local room. I'm swingin for some zepplin.

BTW have you guys tasted bicitra?

 

[militarymd]

BTW have you guys tasted bicitra?

 

[jetproppilot]

If she is awake with minimal sedation and blows a preternatural geyser of bile out her mouth, but can cough/gag/respond coherently (ie can protect her airway), would you then proceed to intubation? Or do you suction and wait for the dry heaves?

Lez say the pt is pain free from the CSE and the sats are steady. Presumably the n/v is from the surgeon pullen on the vicera.

Lez say your I-POD fries and all you have left is the eight track in the local room. I'm swingin for some zepplin.

BTW have you guys tasted bicitra?

Nah, just let her clear it.

HAH! Bicitra...

did a shot with a patient just the other night. Kinda cracks 'em up. Love the stuff.

Might enhance it with a sugar rim on one of those long nights.

 

[jwk]

JWK, do you guys monitor FHTs intraop?

Nope - those belts that hold the external probes get in the way. We check pre/post-op, that's it.

And as far as Bicitra - it's pretty mild compared to some of the shooters I've done over the years. Hey, if you can do Jagermeister, you can drink anything.

 

[Monty Python]

the baby kept kicking John the surgeon's hand throughout the whole procedure.

JPP: Please tell Indo hi for me, and if he still has my T-Birds tape can he return it? Doubtful, I know.

Regarding Bicitra, it's a good antacid (and palatable) if you mix it 50/50 with warm tap water. Does a good job of eliminating the bitterness and shocking aftertaste.

 

[IceDoc]

BTW have you guys tasted bicitra?

We have minty fresh Bicitra! 😀 Tastes not unlike Milk of Magnesia.

 

[Noyac]

I'm swingin for some zepplin.

BTW have you guys tasted bicitra?

Bictra was common for me after eating at the Cafeteria in New Mexico during residency. The food was OK but the red chile was wicked.

Zepplin "No Quarter" full tilt.

 

[jetproppilot]

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