Do you damn the torpedos with this case?

[Arch Guillotti]

---

Members do not see this ad.

This was a dilemma that I faced a while back but will try to reconstruct it as best as possible because I can't remember all the specific details.

So it is the first case of the day. You have a 75 year old guy in the outpatient surgical center. He seems just like a typical old crusty VA type of dude and in fact he is. Normally he gets his care at the VA, and you do not have access to those records. He is having an optho procedure that should take about 2-3 hours and is normally done with an ETT(at this facility at least).

History of smoking 2-3 packs a day for 60 years. Uses oxygen at home at night sometimes and sometimes during the day if he exerts himself too much and yes he still smokes. His exercise tolerance is piss poor as you can well imagine. Exercise involves grabbing another cancer stick.

He also has a history of HTN that is fairly well controlled. Hx of CHF as well with several past admissions to the hospital (no tubes). He has seen a cardiologist within the last six months and is on all the right meds including 40 of lasix bid. Echo shows a normal EF but he does have diastolic dysfunction.

He's a skinny fella with a good airway. Room air sats are in the mid 90's. No peripheral edema. EKG shows some minor nonspecific changes.

Everything is fine so far except when I listen to his lungs he has some very mild crackles about 1/3 of the way up. No prior cxray is available for comparison. The preop assessment form from 3 days earlier notes his lungs are clear but I didn't know the person who interviewed him so who knows how carefully they listened.

He did not take his lasix because "they told me NOTHIN' by mouth after midnight". He doesn't appear short of breath and he says he feels just like he always does. This guy is never gonna be "tuned up" completely and everthing looks good but the lung sounds are a little troubling.

The clock is ticking, the surgeon is tapping his toes. You have another room to start a general plus a block to place.

What do you do?

Get a cxray? Give him lasix? Cancel? Damn the torpedos?

 

[Fastrach]

Nuthin like a little positive-pressure ventilation to reduce that pulmonary edema a little... I say yeah, give a lil' sluggo lasix along with your etomidate/roc/tube and get on with your life... besides, you can't kill a vet anyways. 🙄

 

[jetproppilot]

An eye case, as you know, involves no fluid shifts, no need for IV fluids in excess.

He's as optimized as he'll ever be.

He walked into the hospital right?

Put him to sleep.

Minimize preoperative benzodiazepines and intraoperative opiods.

Keep the IVF to a minimum.


Like Ben Stiller said in Starsky and Hutch,


"JOHNNY RED NEAT. DO IT."

Whenya get to the PACU, fire up a Marlboro Red Inna Box for the Dude to make him feel at home.

 

[mille125]

This was a dilemma that I faced a while back but will try to reconstruct it as best as possible because I can't remember all the specific details.

So it is the first case of the day. You have a 75 year old guy in the outpatient surgical center. He seems just like a typical old crusty VA type of dude and in fact he is. Normally he gets his care at the VA, and you do not have access to those records. He is having an optho procedure that should take about 2-3 hours and is normally done with an ETT(at this facility at least).

History of smoking 2-3 packs a day for 60 years. Uses oxygen at home at night sometimes and sometimes during the day if he exerts himself too much and yes he still smokes. His exercise tolerance is piss poor as you can well imagine. Exercise involves grabbing another cancer stick.

He also has a history of HTN that is fairly well controlled. Hx of CHF as well with several past admissions to the hospital (no tubes). He has seen a cardiologist within the last six months and is on all the right meds including 40 of lasix bid. Echo shows a normal EF but he does have diastolic dysfunction.

He's a skinny fella with a good airway. Room air sats are in the mid 90's. No peripheral edema. EKG shows some minor nonspecific changes.

Everything is fine so far except when I listen to his lungs he has some very mild crackles about 1/3 of the way up. No prior cxray is available for comparison. The preop assessment form from 3 days earlier notes his lungs are clear but I didn't know the person who interviewed him so who knows how carefully they listened.

He did not take his lasix because "they told me NOTHIN' by mouth after midnight". He doesn't appear short of breath and he says he feels just like he always does. This guy is never gonna be "tuned up" completely and everthing looks good but the lung sounds are a little troubling.

The clock is ticking, the surgeon is tapping his toes. You have another room to start a general plus a block to place.

What do you do?

Get a cxray? Give him lasix? Cancel? Damn the torpedos?

Patient is asymptomatic so give him his lasix and go....WNL on preop assessment likely means "we never looked". I would only trust that information if I took it myself. Anyway mild crackles is likely the norm for these typical VA patient.

 

[militarymd]

sounds pretty darn tuned up to me....

no dilemma.

 

[Noyac]

Is it an optho case that needs GA?

This guy ain't gettin any betta.

 

[Arch Guillotti]

He needs GA for this case.

I am interested in hearing from residents and new attendings on this one. This case is old hat to you vets but I find that little things like this pop up ALL THE TIME and I don't have the ability to default to someone else on these matters, and often you just have a very limited amount of time to make these pesky little decisions. Probably the vast majority of time it doesn't make a difference but I think in this case it most likely affected the course of things. Soon as a few more people reply I will post what happened.

"Damn the torpedos" is pretty dramatic, I just like the phrase😛

 

[9french]

This was a dilemma that I faced a while back but will try to reconstruct it as best as possible because I can't remember all the specific details.

So it is the first case of the day. You have a 75 year old guy in the outpatient surgical center. He seems just like a typical old crusty VA type of dude and in fact he is. Normally he gets his care at the VA, and you do not have access to those records. He is having an optho procedure that should take about 2-3 hours and is normally done with an ETT(at this facility at least).

History of smoking 2-3 packs a day for 60 years. Uses oxygen at home at night sometimes and sometimes during the day if he exerts himself too much and yes he still smokes. His exercise tolerance is piss poor as you can well imagine. Exercise involves grabbing another cancer stick.

He also has a history of HTN that is fairly well controlled. Hx of CHF as well with several past admissions to the hospital (no tubes). He has seen a cardiologist within the last six months and is on all the right meds including 40 of lasix bid. Echo shows a normal EF but he does have diastolic dysfunction.

He's a skinny fella with a good airway. Room air sats are in the mid 90's. No peripheral edema. EKG shows some minor nonspecific changes.

Everything is fine so far except when I listen to his lungs he has some very mild crackles about 1/3 of the way up. No prior cxray is available for comparison. The preop assessment form from 3 days earlier notes his lungs are clear but I didn't know the person who interviewed him so who knows how carefully they listened.

He did not take his lasix because "they told me NOTHIN' by mouth after midnight". He doesn't appear short of breath and he says he feels just like he always does. This guy is never gonna be "tuned up" completely and everthing looks good but the lung sounds are a little troubling.

The clock is ticking, the surgeon is tapping his toes. You have another room to start a general plus a block to place.

What do you do?

Get a cxray? Give him lasix? Cancel? Damn the torpedos?

He sounds as well optimized as he can be. I routinely check electrolytes preoperatively in patients with diuretic use, and routinely will get an EKG for patients with a significant cardiac history. Obviously this guy, who I would call an ASA 3+, is at elevated risk for perioperative complications when compared to an ASA 1. Personally, I would be willing to do him in an ASC setting.

Intraoperatively, if general is necessary, I would prefer to use an LMA, as it seems to reduce pulmonary complications immediately post-op.

The big question is how comfortable you are doing this case in an ASC. If you are attached to a hospital and don't have to call an ambulance to admit a patient, you may have a higher tolerance for these borderline patients. On the otherhand, if you are at a freestanding ASC without a good hospital agreement, you may have a lower tolerance.

The politics of your ASC is another issue to take into account. Keep in mind you are evaluated by administration and the surgeons continuously. If you get a reputation of cancelling cases, you may no longer have a job. If you have a high number of hospital admissions or other "preventible" complications, you may get the reputation of a cowboy and also may no longer have a job.

 

[militarymd]

you're wasting someone's money....and Obama will make it so that you will be wasting YOUR own money when you order these silly unnecessary tests.

He sounds as well optimized as he can be. I routinely check electrolytes preoperatively in patients with diuretic use, and routinely will get an EKG for patients with a significant cardiac history. Obviously this guy, who I would call an ASA 3+, is at elevated risk for perioperative complications when compared to an ASA 1. Personally, I would be willing to do him in an ASC setting.

Intraoperatively, if general is necessary, I would prefer to use an LMA, as it seems to reduce pulmonary complications immediately post-op.

The big question is how comfortable you are doing this case in an ASC. If you are attached to a hospital and don't have to call an ambulance to admit a patient, you may have a higher tolerance for these borderline patients. On the otherhand, if you are at a freestanding ASC without a good hospital agreement, you may have a lower tolerance.

The politics of your ASC is another issue to take into account. Keep in mind you are evaluated by administration and the surgeons continuously. If you get a reputation of cancelling cases, you may no longer have a job. If you have a high number of hospital admissions or other "preventible" complications, you may get the reputation of a cowboy and also may no longer have a job.

 

[toughlife]

What are we waiting for to proceed with the case? Christmas?

 

[jd1572]

If he lays down flat and is asymptomatic, then I would assume that he would be OK to lay down flat on the table for induction of GA and hopefully we would be able to extubate him at the end of the case. If he lays down flat and has dyspnea, then I would see if I could get him comfortable with a little reverse Trendelenberg. If he still has serious respiratory distress, then I would consider cancelling the case. If I remember correctly, AHA/ACC guidelines suggest further workup if a patient has uncompensated heart failure.

 

[urge]

Pent, sux, tube.

 

[Arch Guillotti]

What are we waiting for to proceed with the case? Christmas?

Alright there is nothing really exciting here and we proceeded with general anesthesia uneventfully. I did not give lasix. I instructed the CRNA to hold fluids to a "minimum". This turned out to be about 700 cc's or so🙄. So the case ended and the pt. was breathing on his own adequately, nothing spectacular, sort of gagging and bucking on the tube so was extubated without any problem, CO21 in the 50's. I can't recall the exact amount of narcotic dosed but it was pretty on the high end which is pretty much the norm. So off we went to the PACU, when we got there the sats were fine in the mid 90's on a faceshield but the dude just didn't look too good. He wasn't responding too much, kind of moaning, lungs definitely sounded crackly. So after a little while we sent an abg an dammit the pco2 was about 90, he was in hypercarbic resp. failure. Had to figure out how to get the CO2 down.

 

[dfk]

Alright there is nothing really exciting here and we proceeded with general anesthesia uneventfully. I did not give lasix. I instructed the CRNA to hold fluids to a "minimum". This turned out to be about 700 cc's or so🙄. So the case ended and the pt. was breathing on his own adequately, nothing spectacular, sort of gagging and bucking on the tube so was extubated without any problem, CO21 in the 50's. I can't recall the exact amount of narcotic dosed but it was pretty on the high end which is pretty much the norm. So off we went to the PACU, when we got there the sats were fine in the mid 90's on a faceshield but the dude just didn't look too good. He wasn't responding too much, kind of moaning, lungs definitely sounded crackly. So after a little while we sent an abg an dammit the pco2 was about 90, he was in hypercarbic resp. failure. Had to figure out how to get the CO2 down.

any chance doxapram would work here?

 

[Planktonmd]

Pent, sux, tube.

😀
Do you still use Pentothal?

 

[Planktonmd]

any chance doxapram would work here?

Do they still make that stuff?

 

[Arch Guillotti]

Doxapram is still made but I have only seen it used very rarely, and only by a very few attendings. So for this guy I decided to do something that I had not done before and was to put in an LMA to bring down his CO2. He did not need any induction agent to put it in, he willingly accepted it without anything. I sort of assisted him a bit for a while, then I just let him breath on his own since his rate and idal volumes seemed good. After about 30 minutes or so I took it out and he did fine thereafter. I believe he did get admitted overnight, which happens soemtimes with our outpatients and is not taht big of a deal since we are attached to the hospital.

I think that the combination of a crusty old frail smoker w/hx of CHF, no am lasix, maybe more narcotic than he needed for an eye case, and just enough fluid to put him over the edge all contributed to this debacle. That day I learned that an LMA is fine in the PACU to get down the CO2.

Also I think that cases like this can be done on a MICRODRIPPER. One of my biggest frustrations is communicating (so I think) instructions such as this for a case and then having trouble getting said instructions executed appropriately. The same thing has happened to me in a sitting shoulder case when I ask that the BP be kept at the preoperative level only to walk in and find half an hour of SBP's in the 90 charted🙁.


As has been stated previously there is essentially no fluid shifts in a case like this so there is really no need to give any volume (however small) unless you think they REALLY need it. Persons with crappy EF's (bi-v EP lab lab type of pts.) are also very susceptible to fluid overload (duh) and IMHO should be done with as little fluid administration as possible.

When we got to the PACU I did squirt him with 80 of lasix before seeing the cxray and he diuresed well.

 

[urge]

So for this guy I decided to do something that I had not done before and was to put in an LMA to bring down his CO2.

That must have been a scene. What was the rationale behind that?

What kind of fellowship is that?

 

[Arch Guillotti]

That must have been a scene. What was the rationale behind that?

Surprisingly it worked very well. The attending who suggested it to me was a very experienced old guy who had apparently done it before. I think an LMA is better than an ETT because you don't have to get a vent and the outpatient PACU nurses are a little more comfortable with an LMA. How else would you have gotten his pco2 down?

I felt a little sheepish after the case but hey as I have said along the attending learning curve can be just as steep as the residency learning curve at times. I don't think I would have done anything differently other than truly limit his fluid and/or narcotic. I did try to limit both of them but unfortunately I guess I didn't convey my intentions strongly enough🙁.

 

[urge]

Surprisingly it worked very well. The attending who suggested it to me was a very experienced old guy who had apparently done it before. I think an LMA is better than an ETT because you don't have to get a vent and the outpatient PACU nurses are a little more comfortable with an LMA. How else would you have gotten his pco2 down?

So, you think it was due to obstruction? Why not a nasal/oral airway?

 

[Consigliere]

Arch,

Word to the wise: when you are supervising CRNAs you have to be SPECIFIC with them. Don't say "minimize fluids", instead say "don't give more than 200cc for this case". Some need EXPLICIT directions.

Peace out

 

[Arch Guillotti]

Arch,

Word to the wise: when you are supervising CRNAs you have to be SPECIFIC with them. Don't say "minimize fluids", instead say "don't give more than 200cc for this case". Some need EXPLICIT directions.

Peace out

Yeah I know unforunately. I try not to be a "micromanager" but some folks just do not get it, no matter what I politely ask/tell them which can be very frustrating.

 

[Arch Guillotti]

So, you think it was due to obstruction? Why not a nasal/oral airway?

That probably would have been fine as well but likely would have involved me or the other anesthesiologist standing there and having to hold the ambu bag over the guys face for a while and at least assisting him some and neither one of us wanted to be tied down there for a while. I realize this may have been an unconventional (goofy😎) way to do things but hey it got the job done.

 

[urge]

Arch,

I'm trying to imagine how your case would have gone as an oral board exam.


Examiner: CO2 is high. How are you going to fix it?

Arch: I would look for the cause first. This pt has a cardiac history, so chf is a possibility. Residual anesthetic effect, either hypoventilation from narcotics or residual muscle realxation is also possible. There are other rarer causes for hypercapnia such as hypermetabolic state but I would rather begin treating what is more common.

Examiner: How would you treat this patient?

Arch: I would stick an LMA.

Examiner: Say that agan.

Arch: I would stick an LMA.

Examiner: Could you explain why?

Arch: I deally this pt would be intubated and placed on the vent. But, being this an ASC, I don't want to inconvenience the nurses which are not familiar with vented pts. The LMA allows me to treat the pt without a vent.

Examiner: An LMA without a vent will only maintain a patent airway. If this is all the patient needs, why not put an oral/nasal airway?

Arch: The LMA allows me to leave the patient alone so I can keep the schedule running. I might have to ambu the pt for a while if I only put an oral airway.

Examiner: What's the difference between an oral airway and a LMA if the patient is spontaneously breathing?

Arch: LMA allows me to leave about my business.

Examiner: I think we are done. See you next year.

 

[nutmegs]

That probably would have been fine as well but likely would have involved me or the other anesthesiologist standing there and having to hold the ambu bag over the guys face for a while and at least assisting him some and neither one of us wanted to be tied down there for a while. I realize this may have been an unconventional (goofy😎) way to do things but hey it got the job done.

how about bipap?

 

[Arch Guillotti]

Arch,

I'm trying to imagine how your case would have gone as an oral board exam.


Examiner: CO2 is high. How are you going to fix it?

Arch: I would look for the cause first. This pt has a cardiac history, so chf is a possibility. Residual anesthetic effect, either hypoventilation from narcotics or residual muscle realxation is also possible. There are other rarer causes for hypercapnia such as hypermetabolic state but I would rather begin treating what is more common.

Examiner: How would you treat this patient?

Arch: I would stick an LMA.

Examiner: Say that agan.

Arch: I would stick an LMA.

Examiner: Could you explain why?

Arch: I deally this pt would be intubated and placed on the vent. But, being this an ASC, I don't want to inconvenience the nurses which are not familiar with vented pts. The LMA allows me to treat the pt without a vent.

Examiner: An LMA without a vent will only maintain a patent airway. If this is all the patient needs, why not put an oral/nasal airway?

Arch: The LMA allows me to leave the patient alone so I can keep the schedule running. I might have to ambu the pt for a while if I only put an oral airway.

Examiner: What's the difference between an oral airway and a LMA if the patient is spontaneously breathing?

Arch: LMA allows me to leave about my business.

Examiner: I think we are done. See you next year.

Yeah they would probably show me the door. But as I am sure you are aware everyday business in the anesthesia world isn't run like an oral board exam. You can be sure that next year I am going "by the book". To do otherwise is foolish.

 

[Arch Guillotti]

how about bipap?

That is a good thought, but to get the machine to the outpatient area along w/someone who knew how to set it up would require an act of Congress, and we know how effective legislators are.

 

[Arch Guillotti]

Truth be told, a crusty old attending suggested the LMA so I went with it. And he used to be an oral board examiner!

 

[proman]

A peds attending told me a supraglottic airway is a supraglottic airway, so oral airway = LMA in this case. Improved his ventilation while treating his underlying pathology. What's wrong with that? Did he really meet extubation criteria? Any thought to giving naloxone?

 

[Noyac]

Arch,

Dude it worked and thats what counts.

 

[militarymd]

A peds attending told me a supraglottic airway is a supraglottic airway, so oral airway = LMA in this case. Improved his ventilation while treating his underlying pathology. What's wrong with that? Did he really meet extubation criteria? Any thought to giving naloxone?

bingo....I've done what Arch has done before...the LMA is just a bridge before the patient has fully recovered from the effects of general anesthesia....

no different than putting an Oral Airway or nasal trumpet in.