Cool/challenging cases anyone?

[militarymd]

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Anyone?

 

[jetproppilot]

Anyone?

Here's a case I did a cuppla months ago at midnight....

25 y/o female G1 P0 with Marfan's Syndrome, previous Harrington Rods placement, presents to the labor unit in labor needing a C section for CPD.
We brought her to the main OR for the section in case all hell broke loose.
I had her spine xrays, found a cuppla levels I thought I could do a combined spinal epidural at and went to work. Tried for 20 minutes to no avail. Finally got a so-so loss of resistance; spinal needle through the Tuohy never found CSF. Threaded the catheter, dosed it with incremental 2% lido 20ml. Waited a while. Patient can't bend her legs now but has patchy abdominal block. Dose a little more with .5% bupiv. Legs now completely numb, still patchy abdomen block.
WHAT NOW YOUNG GRASSHOPPAS???????

What are your concerns at this point? Whats your Plan Of Action?
She has to be delivered now so walking out and applying at Taco Bell is not an option.

 

[zippy2u]

Grasshoppa say 22G quinke until you hit csf , 1.4cc of spinal marcaine with 25micros of fentanyl and call it finito. It's midnight dude and you're monkeying around with the combined technique in a pt with harrington rods? not the time my friend. ---Zippy

 

[Goose...Fraba]

Jet and Military,
first off just want to say thanks for putting up cases like this, it really stimulates us budding anesthesiologist out here. Im just a lowly M3 soon to be M4 with only 18 chapters of morgan and mikhail + 1 anesthesia rotation under my belt, so Im probably way off, but Ill take a stab.

putting her to sleep, although definatley possible, is not recommended due to aspiration/ fetal problems.

I guess the question is why isnt her epidural working?

If it was a spinal injection, it would have the opposite effect, in other words, she would be completely numb, and may even worry about creating a high spinal due to the higher amounts used in epidurals vs spinal.

if it was a accidental intravascular injection, you would probably be noticing some EKG changes.

My only thoughts are maybe somehow the lidocaine/bupiv. is not getting fully into the epidural space or is diffusing out of the epidural space, so I would try repositioning the catheter, and then test dosing it, and slowly titrate untill you get the desired effect?

Im not sure what harrington rods are, and Im to tired to look em up, but Im assuming they have something to do with the spinal stabilization, so maybe that may be the source of the problem? Not sure if having Marfans would effect the epidural? just my thoughts

goose

 

[Justin4563]

she goes to sleep

suction available.. make it two just in case one fails....... plus minus aline ... I say this because if she has an arch aneurysm you need tight control of the blood pressure.. remember she is pregnant with all the airway risks so do a careful airway exam... if you think she will be difficult choose from your array of awake choices.. If not Preoxygenate.. pent sux tube..... have a stick of something around to lower the blood pressure.. i agree not your typical case and you definitely dont want to put her to sleep but you know if you have to do it.......

 

[zippy2u]

Epidurals and harrington rods don't go together- no way no how. Use either spinal or GETA. Now to answer your question and it would be a hypothetical as I wouldn't have used your technique. Continue giving it some tincture of time. Hold off on any more LA. Give 100 micros of fentanyl incrementally. If after 20 minutes after the fentanyl dose you don't have adequate level then transition to GETA. As an aside the bulletproof epidural soln for c-section is 20 cc of 2% lidocaine with 2cc of NaHCO3 and 100 micros of fresh epi and 100 micros of fentanyl. Mix it in a 30 cc syring and give it incrementally-- you be the man within 10 minutes. ---Zippy

 

[jetproppilot]

Grasshoppa say 22G quinke until you hit csf , 1.4cc of spinal marcaine with 25micros of fentanyl and call it finito. It's midnight dude and you're monkeying around with the combined technique in a pt with harrington rods? not the time my friend. ---Zippy

Good point. Forgot to tell you I did try that in between Tuohy stabs to no avail. Her intrathecal space was unobtainable from all the metal and bone graft crap surrounding it.

 

[jetproppilot]

Epidurals and harrington rods don't go together- no way no how. Use either spinal or GETA. Now to answer your question and it would be a hypothetical as I wouldn't have used your technique. Continue giving it some tincture of time. Hold off on any more LA. Give 100 micros of fentanyl incrementally. If after 20 minutes after the fentanyl dose you don't have adequate level then transition to GETA. As an aside the bulletproof epidural soln for c-section is 20 cc of 2% lidocaine with 2cc of NaHCO3 and 100 micros of fresh epi and 100 micros of fentanyl. Mix it in a 30 cc syring and give it incrementally-- you be the man within 10 minutes. ---Zippy

I humbly disagree, Zip. This was my 3rd Harrington Rod pregnant pt in eight years; the first 2 were otherwise healthy having vag deliveries, and both of them worked well for labor analgesia. Of course it could've gone either way (working vs not working) and I explained to them, "Dudette, this may or may not work." I think its always worth a shot. Again, their epidural space may be anatomically irregular after the surgery but you never know what dermatomes will have analgesia until you try.

 

[zippy2u]

I'll also play midnight cowboy for ya. If ya got a skin-to-skin in 20 minutes c- section OB guru with a patchy abdominal level lady, judiciously sink ketamine 10 mgs increments IV to cover the patchiness. In your lady, labetalol in 5mg aliquots would be appropriate to offset the ketamine hemodynamics.

 

[militarymd]

I'm not sure what's going on with the intrathecal catheter. Perhaps this lady has some scarring that has led to compartmentalized intrathecal space, preventing the catheter from working properly.

I would likely going ahead and put her to sleep for the C-section. The risks of aspiration date back from the days when C-sections get masked for the duration of the case.

In Germany, 70 to 80 percent of elective C-sections are done under general...and safely without adverse outcome for mother or baby.

 

[militarymd]

I'm not sure what's going on with the intrathecal catheter. Perhaps this lady has some scarring that has led to compartmentalized intrathecal space, preventing the catheter from working properly.

I would likely going ahead and put her to sleep for the C-section. The risks of aspiration date back from the days when C-sections get masked for the duration of the case.

In Germany, 70 to 80 percent of elective C-sections are done under general...and safely without adverse outcome for mother or baby.

Wait, I misread, it is an epidural catheter...sorry...but I would proceed the same way as above.

 

[juddson]

hey,

Question from know-nothing newb just going into his M2 year: as I understand it, the epidural is given in the L3 to L5 region, which is safely within the cauda equina region, right? That being the case, the risk of hitting a nerve with the needle is low, isn't it (like poking cooked spagetti). Still, is the risk zero?

Also, the epidural space is continuous from the top of the spinal cord to the bottom, right? If I'm right about that, why doesn't the lidacane diffuse up the space and case numbness in the arms as well?

I know it's way basic - but I figure, what the hell.

Judd

 

[UTSouthwestern]

hey,

Question from know-nothing newb just going into his M2 year: as I understand it, the epidural is given in the L3 to L5 region, which is safely within the cauda equina region, right? That being the case, the risk of hitting a nerve with the needle is low, isn't it (like poking cooked spagetti). Still, is the risk zero?

Also, the epidural space is continuous from the top of the spinal cord to the bottom, right? If I'm right about that, why doesn't the lidacane diffuse up the space and case numbness in the arms as well?

I know it's way basic - but I figure, what the hell.

Judd

Risk is not zero: You can skewer a nerve if you are too aggressive and pop through the dura.

Typically, we do not give enough of the medications to reach the cervical region where most of the nerves of the arms originate. A general rule for number of levels covered by your injectate is 1-2 cc's per level to be covered by the epidural.

 

[jetproppilot]

I'll also play midnight cowboy for ya. If ya got a skin-to-skin in 20 minutes c- section OB guru with a patchy abdominal level lady, judiciously sink ketamine 10 mgs increments IV to cover the patchiness. In your lady, labetalol in 5mg aliquots would be appropriate to offset the ketamine hemodynamics.

Dude, you're obviously an anesthesiologist extraordinairre. Very good clinical interventions. Unfortunately this OB lady takes over an hour for a C section.

 

[jetproppilot]

Anyone?

OK OK OK OK OK (what was that movie where Joe Peschi kept saying "OK OK OK"....one of the Lethal Weapon flicks?

Judson brings up a great point about the epidural space being continuous- thats pretty much correct unless the space has been compromised by spine surgery, making it not continuous. Hence this lady's patchy block. I wish I could've accessed her intrathecal space, but I couldnt. And I consider myself at least as deft as Military with anesthesia procedures.

Another salient point for all budding anesthesiologists out there is there is no RIGHT way to do a case. As long as you are using your knowledge base you acquired in residency and post-residency experiences, and you practice within standard of care, getting the patient through the surgery can usually be done 20 different ways.

HERES HOW I DID IT:

OK OK OK....I REALLY didnt want to put this lady to sleep...would much rather have had the neuraxial-blockade-induced- low SVR to protect her fragile aorta...but regional anesthesia had failed in the presence of a very skilled clinician... (HAHAHAHAHA...I'm a legend in my own mind...I mean time... )..so I slid in an A-line so I could watch her BP beat-to-beat, pre 02, propofol, sux, waited until I was pretty sure she was deep enough, and did a quick laryngoscopy, slid the tube in, looked at the A-line tracing, BP still OK (read not rising), and told the surgeon to GET BUSY.

The rest of the case was without incident.

Military brings up a great point about GA in the parturient. Yes, there are aspiration risks, but in real life, academia has made clinicians think THERES NO WAY YOU SHOULD PUT A PREGNANT WOMAN TO SLEEP BECAUSE SHE WILL CERTAINLY DIE IF YOU DO...when in fact thats not the case. Yes, there are risks, but the risks can be drastically minimized in the hands of an astute clinician.

Very, very nice posts to all who posted.

 

[militarymd]

And I consider myself at least as deft as Military with anesthesia procedures.

I'm the president of SARA (Society Against Regional Anesthesia)......I give up on regional anesthesia procedures pretty fast 🙂

My preop to patients: (in heavy oriental accent) "you go to sleep now"

 

[Idiopathic]

I'm not sure what's going on with the intrathecal catheter. Perhaps this lady has some scarring that has led to compartmentalized intrathecal space, preventing the catheter from working properly.

I would likely going ahead and put her to sleep for the C-section. The risks of aspiration date back from the days when C-sections get masked for the duration of the case.

In Germany, 70 to 80 percent of elective C-sections are done under general...and safely without adverse outcome for mother or baby.

The textbooks (ergo the law?) would rather you not do this. I was reading about it today, in fact. Do you sleep many of your CS patients?

 

[juddson]

Pardon me, but "aspirate" what, exactly? Isn't this a controlled environment? Why is there a risk of aspiration when doing a general?

judd

 

[jetproppilot]

Pardon me, but "aspirate" what, exactly? Isn't this a controlled environment? Why is there a risk of aspiration when doing a general?

judd

Anatominc and hormonal changes in the parturient decreases gastric amptying time with concominant increase in residual gastric volumes; hence the risk of aspiration, either passive, or active following mask ventilation in the face of falling oxygen saturation secondary to decreased parturient FRC.

 

[jetproppilot]

Anatominc and hormonal changes in the parturient decreases gastric amptying time with concominant increase in residual gastric volumes; hence the risk of aspiration, either passive, or active following mask ventilation in the face of falling oxygen saturation secondary to decreased parturient FRC.

sorry, thats gastric EMTYING.

 

[jetproppilot]

sorry, thats gastric EMTYING.

OK, LAST TIME, EMPTYING. Can you tell I have my contacts out?

 

[militarymd]

The textbooks (ergo the law?) would rather you not do this. I was reading about it today, in fact. Do you sleep many of your CS patients?

I don't do GA on many of my C-Sections because in N. American, there is the expectation of being awake with your significant other in attendance while you have major abdominal surgery.

However, I have no qualms about putting someone to sleep for this if necessary.

 

[juddson]

Anatominc and hormonal changes in the parturient decreases gastric amptying time with concominant increase in residual gastric volumes; hence the risk of aspiration, either passive, or active following mask ventilation in the face of falling oxygen saturation secondary to decreased parturient FRC.

Ok, but this is a risk only after the pt has been extubated, right? And, this is not a risk if the pt has not eaten in 12 hours, right? Or is there more to this?

Judd

 

[juddson]

Anatominc and hormonal changes in the parturient decreases gastric amptying time with concominant increase in residual gastric volumes; hence the risk of aspiration, either passive, or active following mask ventilation in the face of falling oxygen saturation secondary to decreased parturient FRC.

Ok, but this is a risk only after the pt has been extubated, right? And, this is not a risk if the pt has not eaten in 12 hours, right? Or is there more to this?

and isn't this a risk in all trauma surgeries and all non-elective surgeries as well when you don't know the last time somebody ate something.

Judd

 

[jetproppilot]

Ok, but this is a risk only after the pt has been extubated, right? And, this is not a risk if the pt has not eaten in 12 hours, right? Or is there more to this?

Judd

Aspiration is a risk for intubation and extubation, regardless of when she has eaten last (even if she hasnt eaten in 12 hours). Take a look in Baby Miller or any other anesthesia text under OB anesthesia and read the part about "physiologic changes in the parturient", which UT could list all of them, since he is probably getting ready for boards.
Find the area concerning GI changes in pregnancy...it'll give you a better understanding about the attendant anesthesia implications.

 

[cubs3canes]

Awesome case...where is the next one?

 

[Justin4563]

Dont forget when you wake her up.. do your chinese accent and say , " OPEN YOUR EYE"//

 

[Monty Python]

Awesome case...where is the next one?

This is how I rang in the new millenium, January 1, 2001. Moonlighting in the swamps of South Louisiana.

ER beeps me around 1000. "Guy with stuck gallstone and Dr. X wants a lap chole." I think, fine, I know Dr. X to be a very quick, talented, and logical surgeon, and damned good with laparoscopic technique.

Things went downhill rapidly when I went to the ER to preop the pt, and discovered:

1. septic cholelithiasis
2. long term chronic renal failure with multiple AV fistula, grafts, etc, which the pt frequently used for his recreational drug abuse
3. cocaine addict
4. eyes as yellow as Paris Hilton's hair
5. and the grand prize: pt is on the list for mitral and aortic valve replacements when he can find a charity/university hospital to take him. All local private and university systems have refused him, due to his total non-compliance with medical instructions. EF (according to pt) is 15%.
6. A hunch told me marked portal hypertension (confirmed during laparoscopy).

Now, I'm just moonlighting there. This is not my fulltime hospital. It's a little 50 bed general hospital in a small town. No cardiac guys, no bypass capability, etc. I was about to suggest turfing this guy elsewhere to the surgeon when, surprise, in walks the head of the anesthesia department (who was off-duty and off-call, but someone beeped him when they realized the ASA 9E status of this pt).

I pulled him aside, gave him a full run-down on this gem, and suggested turfing. Overruled. I then suggested all the big guns (a-line, PA cath, etc.). Overruled. I was about to tell him to do the case himself when I remembered I was there under contract and I had doubts about my legal ability to walk away (in retrospect I should have - although at that point in time I was still very junior, only out of school a couple of years, and not fully aware of my right to refuse to do a case).

Into the OR after I insisted the dept head co-sign my pre-op, so now he's legally involved and on the clock. Normal induction, no problems with intraop management, gallbag out and skin closed in 30 minutes. I suggest slow wake up. Overruled. In go (personally pushed by the dept head): full doses of neostigmine, glyco, romazicon, and narcan. That's 0.4 mg narcan slammed to counteract a whopping 100 mics of fentanyl (30 minutes old).

45 seconds later the pt sits straight up, I extubate, and he falls back to the OR table. I apply mask and notice, hmmmm this is not good: no fog on the mask, no chest movememt. Bagging the pt gives chest excursion but no ETCO2 because this guy's now dead as a doornail. ACLS x 45 minutes just a waste of time.

Happy New Year.

 

[UTSouthwestern]

What a waste of a good lap chole.

 

[Monty Python]

Anyone?

While this does not rank up there with brain transplants, etc., it was very memorable to me.

I was at sea, on board an aircraft carrier. 👍 Surgeon pages me for an incarcerated hernia.

Otherwise healthy pt, non-eventful induction and maintenance, then halfway through the case I start to feel REALLY queasy.

Now, consider this: the OR on an aircraft carrier is intentionally put on the waterline deck, amidships in all aspects, to reduce roll, pitch, and yaw as much as possible.

I looked up from my stool to see the IV bag rocking back and forth as the ship cut through some pretty rough seas. I tried to distract myself by peering over the ether screen, to see what the surgeon was up to. First thing I noticed is peritoneal fluid swishing back and forth. I think "I'll just call for a break." Wait, I am the entire anesthesia department. 😱 Great.

Luckily some peppermints and gum kept in my shoulder bag came to the rescue. Still, it was not a pleasant experience.

 

[militarymd]

Now, consider this: the OR on an aircraft carrier is intentionally put on the waterline deck, amidships in all aspects, to reduce roll, pitch, and yaw as much as possible.

Now, I've never been on a Nimitz class carrier, but I have many colleagues who were underway on them, and I could have sworn that they said the OR was right underneath the flight deck.

Now I'm very familiar with the LHDs...Harrier / marine aircraft carriers, and their ORs are definitely well above the waterline.

 

[Monty Python]

Now, I've never been on a Nimitz class carrier, but I have many colleagues who were underway on them, and I could have sworn that they said the OR was right underneath the flight deck.

Now I'm very familiar with the LHDs...Harrier / marine aircraft carriers, and their ORs are definitely well above the waterline.

On Nimitz-class carriers (I was on USS George Washington, CVN-73) right under the flight deck is the cavernous hangar deck, one huge open space with it's ceiling the equivalent of being 5 stories above it.

The deck containing the medical spaces is one or two decks below the hangar deck (memories from 2000 are a bit hazy these days).

I do clearly remember my stateroom-mate saying that we were sleeping just below the waterline, and my stateroom was one deck lower than the medical deck.

Your friends may have thought the OR was just below the flight deck due to aircraft noise. Steam-catapault takeoffs and "controlled crash" landings utilizing the arresting cable are incredibly noisy. Despite sleeping the equivalent of 8-9 stories below the flight deck, the first time they practiced night touch and gos at midnight I thought a train locomotive was about to crash into my room it was so noisy.

Time to tease and dangle a carrot here: Jetproppilot have you ever considered joining the reserves and being a reserve flight surgeon? Not up to speed on USAF specifics, but in the USNR you go through flight training at Pensacola up through initial solo in a T-34C (turbocharged military version of a Beech Bonanza). Then just one weekend a month for drill, plus as the squadron flight surgeon you're on flight status, meaning you can (and indeed, are expected to) hop into any open backseat when you want to punch holes in clouds. There's two separate USNR squadrons within 15 minutes of your house, one flying P-3 antisubmarine patrol planes, the other flying F-18s.

Sorry for the off-topic meanderings.

 

[jetproppilot]

On Nimitz-class carriers (I was on USS George Washington, CVN-73) right under the flight deck is the cavernous hangar deck, one huge open space with it's ceiling the equivalent of being 5 stories above it.

The deck containing the medical spaces is one or two decks below the hangar deck (memories from 2000 are a bit hazy these days).

I do clearly remember my stateroom-mate saying that we were sleeping just below the waterline, and my stateroom was one deck lower than the medical deck.

Your friends may have thought the OR was just below the flight deck due to aircraft noise. Steam-catapault takeoffs and "controlled crash" landings utilizing the arresting cable are incredibly noisy. Despite sleeping the equivalent of 8-9 stories below the flight deck, the first time they practiced night touch and gos at midnight I thought a train locomotive was about to crash into my room it was so noisy.

Time to tease and dangle a carrot here: Jetproppilot have you ever considered joining the reserves and being a reserve flight surgeon? Not up to speed on USAF specifics, but in the USNR you go through flight training at Pensacola up through initial solo in a T-34C (turbocharged military version of a Beech Bonanza). Then just one weekend a month for drill, plus as the squadron flight surgeon you're on flight status, meaning you can (and indeed, are expected to) hop into any open backseat when you want to punch holes in clouds. There's two separate USNR squadrons within 15 minutes of your house, one flying P-3 antisubmarine patrol planes, the other flying F-18s.

Sorry for the off-topic meanderings.

Great proposition, Trinity. As you know, I'd give my left..uh...Leydig cell holder to ride in that kinda hardware, let alone fly it! The only problem is that proposition has a big downside...namely being deployed for long periods in times like this, away from my wife and kids. Thanx but no thanx.

 

[rn29306]

As you know, I'd give my left..uh...Leydig cell holder to ride in that kinda hardware..

Never heard it put that way before, very nice.

 

[anesthesiaman]

when I had to make my first cross country solo flight vfr of course, i was on my way back home in my dinky rented 172 and experienced extreme nausea, diaphoretic and everything.

to make it worse, there was this strange cloud cover over texas/ark that wasn't really clouds but looked more like endless ocean of hazy smoke. maybe smog i don't know, but it wasn't there before, nor reported. plus it was over the frickin country with no cities anywhere. the smoke only allowed me to see directly below me which was no help. so, now i can't see any of my landmarks, and I have lost track of where I am.

i almost vomited in the co pilot's feet area (i was too afraid to open my door!).

So i focused on the horizon to try to ease the nausea and changed to a higher altitude where I was out of the smoke and at least could be seen by other planes. I used the VORs to find out where I was and to guide me back home. Took me longer than I had planned so I got an hour of night flight out of it.

I would share an anesthesia story, but I'm just a fresh CA-1.

 

[jetproppilot]

when I had to make my first cross country solo flight vfr of course, i was on my way back home in my dinky rented 172 and experienced extreme nausea, diaphoretic and everything.

to make it worse, there was this strange cloud cover over texas/ark that wasn't really clouds but looked more like endless ocean of hazy smoke. maybe smog i don't know, but it wasn't there before, nor reported. plus it was over the frickin country with no cities anywhere. the smoke only allowed me to see directly below me which was no help. so, now i can't see any of my landmarks, and I have lost track of where I am.

i almost vomited in the co pilot's feet area (i was too afraid to open my door!).

So i focused on the horizon to try to ease the nausea and changed to a higher altitude where I was out of the smoke and at least could be seen by other planes. I used the VORs to find out where I was and to guide me back home. Took me longer than I had planned so I got an hour of night flight out of it.

I would share an anesthesia story, but I'm just a fresh CA-1.

Nice story Dude! BTW, CA-1s can post stories too, but I'd rather read flying stories.

I had a similar situation with smoke while flying a 182. I had flown a buddy to Tensas, Louisiana so he could look at and fly a Pitts 2 seater. Dude was one of our CRNAs at the time named Troy..he had an Acroduster at the time (which he later had to bail out of during an acrobatic competition, but thats another story)...flew him to Tensas, he flew the Pitts (didnt end up buying it), I got a bunch of great video. We subsequently loaded up and headed back.
Approaching our home airport from the east, I can see a huge smoke layer in the distance (it was otherwise a severe clear day). As I flew closer it was obvious we were gonna hit it. And this is before I was instrument rated. 😱 As I flew over Esler Field (about 15-20 miles from our home field) the smoke wisps started engulfing the 182....I could see blue sky periodically above, and ground below, but only a mile or so ahead.

Me: "Polk Approach, Cessna six zero eight six fox, we're in this smoke layer and forward vis is pretty low....request vectors to the active at AEX."

"Cessna 6 0 8 6 foxtrot, roger. Whats your forward visibility?"

"About five miles." (I fudged it a little)

"Roger. Turn right heading three-one-zero and I'll put you on a left base for runway one-four."

So I'm flying along at 1500 feet msl and I can't see squat forward but I can see the ground. The controller kept giving me position updates.

"Cessna 6 0 8 6 Foxtrot, Alexandria is twelve o clock, eight miles, report in sight."

"Roger that."

"Cessna 6 0 8 6 Fox, Alexandria twelve o clock, five miles. Do you have the airport?"

"Negative. Still looking."

Now I'm getting a little uneasy. FIVE miles and I cant see the airport....great job, Charles Lindbergh, I thought to myself...

A minute or so passed and I keyed the mike:

"Polk Approach, am I getting close?"

"Uhhh, Cessna 6 0 8 6 Fox, Alexandria is twelve o clock, ONE MILE...."

Just then I look down to my left and I see the big numbers 1 4 on the runway threshold, and they pass to my left.

"Polk Approach, airport in sight, request circle-to-land runway three two."

"Cessna 6 0 8 6 Fox, circle to land granted, contact tower one-twenty-seven-thirty-five."

So I set up on a left base for three two dropped to about 600 feet, descended and banked left like an A-10 Warthog, and landed on three-two.

MAN, thank God I've got my instrument ticket now.