Fun call case

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fakin' the funk

fakin' the funk

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Open for med students and junior residents to share their questions or spout off.

87F, PVD, scleroderma, Hungarian speaking only, for AKA due to foot gangrene

Anything else you wanna know?
Anything you wanna say or know about any of the comorbidities?
What's your plan?
 
Interesting case. There are many things I'd been concerned about here. This guy is old and has bad peripheral vascular disease, so theres a decent chance he also has significant coronary disease. Any h/o MI, CABG? Echo? Exercise tolerance? Probably not much with a dead foot.

With the scleroderma, I'd be concerned about a couple of things. First, a lot of those patients have esophageal dysmotility and can potentially also be difficult airways--any intubation history? Can he open his mouth? I'd probably have at least a glidescope available for backup. Second, I'd be worried about pulmonary hypertension and RV dysfunction, even if he had a relatively recent diagnosis of scleroderma.

There are a couple of different ways to do this case. I would probably choose a straight general anesthetic with a pre induction a-line and double catheters (pop/femoral). Etomidate for RSI induction, again depending on the airway. In theory, one could use only double catheters +/- some sedation, but I don't think it would be my preferred technique.
 
bcat85 said:
With the scleroderma, I'd be concerned about a couple of things. First, a lot of those patients have esophageal dysmotility and can potentially also be difficult airways--any intubation history? Can he open his mouth? I'd probably have at least a glidescope available for backup. Second, I'd be worried about pulmonary hypertension and RV dysfunction, even if he had a relatively recent diagnosis of scleroderma.
Click to expand...
Do CREST patients have pulmonary hypertension?
bcat85 said:
There are a couple of different ways to do this case. I would probably choose a straight general anesthetic with a pre induction a-line and double catheters (pop/femoral). Etomidate for RSI induction, again depending on the airway. In theory, one could use only double catheters +/- some sedation, but I don't think it would be my preferred technique.
Click to expand...
Pre-induction A-line? Why not just induce slowly with frequent BP checks, and see how he behaves? It's an amputation; it shouldn't take long. Shouldn't even have much blood-loss (tourniquet). Would you put in the A-line even if he had Raynaud's?

And forget the etomidate; the oral board examiners will tell you that it's not available. What's your alternative plan for induction? Would you induce with ketamine? How about inhalational induction?

Would you use an LMA? How about a ProSeal/Supreme LMA?

Would you use nitrous oxide for maintenance?

Could you do this case with neuraxial anesthesia? What's wrong with doing it under regional/neuraxial anesthesia and sedation?

Why/not? (for every question/answer).
 
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1. Go to the OR.
2. +/- Pre-induction A-line depending on your comfort level.
3. Prop/Sux/Tube (as long as his K is not 7). Oh and have an LMA handy just in case.
4. Next case.

ohh, this is for med students and residents. oops.
 
the patient is a she not a he guys... as you might expect
 
gasp said:
1. Go to the OR.
2. +/- Pre-induction A-line depending on your comfort level.
3. Prop/Sux/Tube (as long as his K is not 7). Oh and have an LMA handy just in case.
4. Next case.

ohh, this is for med students and residents. oops.
Click to expand...
For the residents: Does the patient need an A-line, at all?
 
No art line unless chart review reveals some nasty active cardiac condition/valve/etc. SAB v. GA depending on pts pulm and coag status. Dual PNB's is a bad way to do this case since an AKA also gets into Obtrurator territory. Knowing 'funk there is probably some obscure anesthesia related concern with scleroderma (aside from the airway and esophageal dysmotility points already mentioned) that I can't think of and am too lazy to look up.😀
 
FFP said:
Do CREST patients have pulmonary hypertension?
Click to expand...

Status: Student (aka useless, know nothing)
Yes.

CREST (Calcinosis cutis, Raynaud, oEsophageal dysmotility, Sclerodactyly, Telangiectasia) is an old term used to describe a subset of patients with limited cutaneous scleroderma although it's recognised that these appear in diffuse cutaneous scleroderma too.

Limited cutaneous scleroderma vs. Diffuse cutaneous scleroderma are differentiated based on how much of the skin is involved. I guess that may have implications on vascular access but you guys are all awesome.

GI problems are many (e.g. difficult mouth opening, reflux, GI bleeding, diarrhoea .......) may have implications on intubation but again you guys are all awesome, so no problem there.

Lung problems are bad. Whichever form you have (limited or diffuse) you can get pulmonary arterial hypertension (+/- pulmonary fibrosis). Kidney problems are bad too but usually only in diffuse scleroderma. Cardiac conduction fibrosis is bad too. What can I say, it's not a good disease.

Source: Rheumatology cougar.

edit:

"Regional anesthesia may be technically difficult because of the skin and joint changes that accompany scleroderma. Attractive features of regional anesthesia include peripheral vasodilation and postoperative analgesia. Measures to minimize peripheral vasoconstriction include maintenance of the operating room temperature above 21C and administration of warmed intravenous fluids." - Stoelting's Anesthesia and Co-existing Disease (5th ed.)
 
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The "old term" is still valid. Pulmonary HTN can appear in both, indeed, and is typically more severe in CREST patients (counterintuitively).
 
Spinal with phenylephrine drip. Light sedation of your choice.

I would stay away from radial a lines. In fact, I would try to avoid placing an a line unless the pt looks really frail.

I would ask for an echo if pt is mostly bedridden.
 
FFP said:
Do CREST patients have pulmonary hypertension?

Pre-induction A-line? Why not just induce slowly with frequent BP checks, and see how he behaves? It's an amputation; it shouldn't take long. Shouldn't even have much blood-loss (tourniquet). Would you put in the A-line even if he had Raynaud's?

And forget the etomidate; the oral board examiners will tell you that it's not available. What's your alternative plan for induction? Would you induce with ketamine? How about inhalational induction?

Would you use an LMA? How about a ProSeal/Supreme LMA?

Would you use nitrous oxide for maintenance?

Could you do this case with neuraxial anesthesia? What's wrong with doing it under regional/neuraxial anesthesia and sedation?

Why/not? (for every question/answer).
Click to expand...


As above, CREST patients do have pulmonary HTN, though it does tend to be a late manifestation of disease. There's no reason for a pre induction a-line from the get-go just with the given comorbidities, but if the patient had anything that suggested that he may have pulmonary HTN, I would go for it. I'd rather have the monitor in place than attempt to place it emergently if things go south. That said, this is not an emergent case, and it would be reasonable to get an echo if the patient was bed bound, as another poster mentioned. Ketamine would be fine, but I would probably pass on the inhalational induction unless the patient had no reflux symptoms. No LMA (aspiration) and no nitrous (again, the pulmonary HTN).

You could definitely do the case with neuraxial though, as someone pointed out earlier, there is likely to be some obturator coverage that would be missed with a pure regional technique. Management hinges mostly on whether the patient has any cardiopulmonary manifestations of his scleroderma.
 
Noyac said:
^^^obturator will not be missed with a spinal.
Click to expand...

Indeed. I meant that there may be incomplete coverage while just doing a pop/saph regional technique
 
For those wanting an echo...I get why it would be reasonable, but how exactly other than convincing you to place a pre op A line if she had pulm HTN might it change your management?
If it showed mild to mod pulm HTN would you place one?
What if in pre-op holding area you can't get either radial A-lines because of her PVD? Do you keep trying? brachial/axillary? (Circulator is shouting "room is ready when you are doctor")
Would you refuse to do this case until the Echo was done, even if surgeon is on your ass that he wants to do it tomorrow AM? Echo tech is gone for the day, and getting it read would delay case further...
Just curious who would insist on an echo for this patient (assuming she has poor functional capacity)
 
Here comes the $64K question: If the patient has pulmonary hypertension, would you place a PAC to monitor it intraop? 🙂
 
I asked for the echo if I cannot get a sense of how much exercise tolerance the pt has. Remember this pt is 87 and with PVD.

I'm not really looking for pulm htn because I'm not going to do anything different.
I'm mostly looking for poor function and valvular disease.

Let's say the echo comes back with 30% ef , mod mr, crtitical AS? I would probably put an a line and a central line for pressors/inotropes then. Watch her in PACU all night, or icu. Chances are the pt will crump overnight.

On the other hand, if I hear the pt is walking around just fine before the gangrene, or if the echo comes back normal then I would just do an iv and send her to the floor.

Is there anyone here who would do anything different if the echo has moderate pulm htn? How about severe?
Can the pulm htn in scleroderma pt be treated?

There is no reason why a PVD pt would not have a cardiac work up done already. If she has not had one, she needs one.

The cases that go bad are usually the ones where you are flying blindly. There is no good reason for that here. This pt can wait a few hrs or even a day for an echo.
 
Colba55o said:
What if in pre-op holding area you can't get either radial A-lines because of her PVD? Do you keep trying? brachial/axillary? (Circulator is shouting "room is ready when you are doctor")
Would you refuse to do this case until the Echo was done, even if surgeon is on your ass that he wants to do it tomorrow AM?
Click to expand...


This is not the pt where you put a lines in holding. Do it in the room with ultrasound available.

We live in a world where any bad outcome in medicine is not tolerated. The amount of paperwork and meetings that come from it should be deterrent enough.

Tell the surgeon he will be presenting at m&m if he insists.
 
urge said:
I asked for the echo if I cannot get a sense of how much exercise tolerance the pt has. Remember this pt is 87 and with PVD.

I'm not really looking for pulm htn because I'm not going to do anything different.
I'm mostly looking for poor function and valvular disease.

Let's say the echo comes back with 30% ef , mod mr, crtitical AS? I would probably put an a line and a central line for pressors/inotropes then. Watch her in PACU all night, or icu. Chances are the pt will crump overnight.

On the other hand, if I hear the pt is walking around just fine before the gangrene, or if the echo comes back normal then I would just do an iv and send her to the floor.

Is there anyone here who would do anything different if the echo has moderate pulm htn? How about severe?
Can the pulm htn in scleroderma pt be treated?

There is no reason why a PVD pt would not have a cardiac work up done already. If she has not had one, she needs one.

The cases that go bad are usually the ones where you are flying blindly. There is no good reason for that here. This pt can wait a few hrs or even a day for an echo.
Click to expand...

I wouldn't mind an echo although I'm not sure I'd postpone if it wasn't done. Physical exam should rule out most of the really serious stuff, so if I don't hear any rip roaring murmurs, patient has no jvd, can lie flat, and isn't massively edematous with crackles up both lungs Id proceed sans echo. As far as pHTN, I'm much more likely to avoid mild hypoxia and hypercapnea if I know it's present, basically meaning if I went with a spinal the patient will only get light sedation (which would be better anyway).

So, I've talked myself into doing the case under spinal, isobaric bupi, with a nicely running iv, and a little midaz for sedation.
 
I think that the severity of this patients pulm HTN definitely needs to be considered. If the patient has severe pulm HTN (i.e. PA pressures approaching systemic pressures), my favoritism towards a spinal is going to be a lot less. I would want as stable of an anesthetic as possible given that bad pulm HTN can act a lot like critical AS of the right side of the heart (necessary to keep pre-load and pressure up, etc). How you accomplish said stable anesthetic is up to you (incrementally dosing neuraxial technique versus cardiac induction, etc). The pulmonary HTN can also certainly affect how much sedation you give a patient given the effect on respiratory drive and impending hypercarbia/hypoxia.

Can't talk the surgeon into a BKA and go for a pop/saph?

Also, this patient may have potentially terrible pulmonary status. Haven't heard any more about it aside from the intro to the patient. Pulmonary cripple on O2 at home?

Would it prevent me from doing the case? No. She has a gangrenous foot. She is getting the surgery. However, it might sway me into a more typical cardiac induction, spinal catheter with incremental dosing, etc. It would also sway me into a pre-induction arterial line. I do agree that you can rule a lot of this out with a thorough H&P. Except in this oral boards scenario she just took her plavix that morning. So all things neuraxial are out. Besides, Potentially dropping the SVR and pre load in a patient with severe pulm HTN sounds like a terrible idea.
 
epidural catheter placed pre-op for post op pain control. bouls with 8-10cc 2% lido before incision. breath down with agent, minimal prop bolus (20-30) before placing an LMA, she breaths spontaneously through lma, neo gtt, we give iv narcotic and other coanalgesics as well as use the epidural catheter for pain control titrated to resp rate. Epidural can stay in for a couple days post op, shes not going anywhere it sounds like. advise the surgical service to use hep gtt or hep sq with catheter in place. only do aline if she behaves unpredictably
 
Hoya11 said:
epidural catheter placed pre-op for post op pain control. bouls with 8-10cc 2% lido before incision. breath down with agent, minimal prop bolus (20-30) before placing an LMA, she breaths spontaneously through lma, neo gtt, we give iv narcotic and other coanalgesics as well as use the epidural catheter for pain control titrated to resp rate. Epidural can stay in for a couple days post op, shes not going anywhere it sounds like. advise the surgical service to use hep gtt or hep sq with catheter in place. only do aline if she behaves unpredictably
Click to expand...
Why do you need GA if you have an epidural?
 
Planktonmd said:
Why do you need GA if you have an epidural?
Click to expand...
so i can give 100% fio2, cpap, ppv if needed, intubate through it if needed, and ensure she is not squirly as shes probably demented and all over the place. id rather give sevo which is nice and stable and self limiting than a prop drip or versed that will cause apnea and hypotension (and delirium with midaz). you dont absolutely need the lma (vs sedation) but it would make it smoother (and easier for the provider).
 
If you've got a good regional block there's the option of zero sedation, which is probably the best option if there is severe PHTN. Even light sedation in these patients can create problems, a little hypoventilation and a little CO2 retention and next thing you know all hell's breaking loose.

If she's demented and squirrelly at baseline that might not work.


Planktonmd said:
Yes, Immediately after the retrograde wire intubation.
Click to expand...
Are you sure it's safe to do the retrograde wire without the PAC in place already?
 
floridaboy18 said:
I think that the severity of this patients pulm HTN definitely needs to be considered. If the patient has severe pulm HTN (i.e. PA pressures approaching systemic pressures), my favoritism towards a spinal is going to be a lot less. I would want as stable of an anesthetic as possible given that bad pulm HTN can act a lot like critical AS of the right side of the heart (necessary to keep pre-load and pressure up, etc). How you accomplish said stable anesthetic is up to you (incrementally dosing neuraxial technique versus cardiac induction, etc). The pulmonary HTN can also certainly affect how much sedation you give a patient given the effect on respiratory drive and impending hypercarbia/hypoxia.

Can't talk the surgeon into a BKA and go for a pop/saph?

Also, this patient may have potentially terrible pulmonary status. Haven't heard any more about it aside from the intro to the patient. Pulmonary cripple on O2 at home?

Would it prevent me from doing the case? No. She has a gangrenous foot. She is getting the surgery. However, it might sway me into a more typical cardiac induction, spinal catheter with incremental dosing, etc. It would also sway me into a pre-induction arterial line. I do agree that you can rule a lot of this out with a thorough H&P. Except in this oral boards scenario she just took her plavix that morning. So all things neuraxial are out. Besides, Potentially dropping the SVR and pre load in a patient with severe pulm HTN sounds like a terrible idea.
Click to expand...
Since when is a spinal a problem in PHTN? Or maybe better wording of the question would be since when is a spinal more of a problem than a general?
In my practice I see severe PHTN all the time. Just pre-op'd a lady yesterday with severe PHTN by echo which showed R atrial enlargement, R ventricular hypertrophy with flattening of the septum, pulm valve insufficiency and PA press estimated to be above 75 with systolic pressures at 105. She was in a wheelchair because, " I'm SOB when I stand". And we do spinals a lot for these Pts.

This case can be done any number of ways, SAB, GA, regional with MAC for example. The key is know what you are dealing with and to stay out of trouble. Personally, I like the SAB or a gentle GA with LMA.

STILL wondering why an AKA? And there is another option which nobody does any longer. If the pt is too sick for surgery just pack the foot in dry ice and let it fall off. It works well. The pt can't feel a gangrenous foot as it is.
 
More on this: I gave the youngsters time to respond didn't i?
Scleroderma at age 87 is significant. Think about how difficult that mannequin is to intubate sometimes. The tissue just won't cooperate. Plus, it is well known that they can't open their mouths well. This could making intubation or even LMA placement difficult. So what's the airway exam look like, fakin?

I'm glad nobody is calling for PFT's. But what would one expect to see on this test? Sev restrictive disease, reduced FVC and possibly preserved FEV1/VC. There is no need to this study because we know the results already.
CXR? Probably shows fibrosis.

SAB is looking better and better, right? Make sure your IV access is good, these people can be difficult in this regard.
 
I agree with Noy that SAB sounds great in this situation. I will also say that the spectre of the pulmonary hypertension death spiral lurks over the case- so if the situation was appropriate for SAB (i.e. cooperative pt, no coag issues, etc), I would give a relatively low dose of isobaric bupi, 7.5-10mg depending on surgeon, which I would expect would maintain smooth hemodynamics. If the heart was really on the edge, I'd even consider a spinal catheter to be incrementally dosed.

I would not slam in 15mg of heavy bupi. That may stir up evil humors.
 
Without wanting to hijack the thread, I see people calling for a "cardiac induction" if GA is chosen.

I think this is an antiquated idea, TBH.

Massive doses of benzos and narcs aren't good for anyone IMO in the modern era, and they sure aren't good for an 87 yo who you might hope would mentate after the procedure is done.

Better ways to skin that cat are out there. I don't ever use high dose benzo/narc inductions, nor do I ever use etomidate. And I do the sickest of the sick cardiac cases.

/hijack
 
Let me guess Hawaiian? Touch of Propofol w/ ketamine? or inhalational induction
 
I don't believe I've ever seen anyone do the classic "cardiac" high opiate induction. Even when I started residency (2006) it was already out of favor.

I take that back. A residency classmate of mine did it once (40 mg of morphine for induction of a GYN case just for grins) and we all heard the unplanned admission story at M&M. 🙂
 
pgg said:
I don't believe I've ever seen anyone do the classic "cardiac" high opiate induction. Even when I started residency (2006) it was already out of favor.

I take that back. A residency classmate of mine did it once (40 mg of morphine for induction of a GYN case just for grins) and we all heard the unplanned admission story at M&M. 🙂
Click to expand...
I have done them. I was a resident back in the early 2000's. I had an attending with a recent Ivory Tower cardiac fellowship that did it for every case. She was by far one of the worst attendings I ever worked with. Ivy towers, hum. Not all is exceptional there. But I'm sure most are.
So this is how we did it. 3 20cc syringes of fentany. Pt gets some versed and then you start pushing the fentanyl. And you just deep pushing it until all 60cc are in. Then 2 days later the pt wakes up. It's perfect. What could be better?
 
Noyac -- don't exactly know why AKA vs BKA. This surgeon (ortho) is not known for finesse or appreciation of nuances. I think the major peripheral vascular lesion in this pt was in the very distal popliteal, raising concern for healing/closure of a BKA.
 
Those who responded -- thanks for your thoughts! Here's a little more info:

Hx: zero functional capacity. Bedbound for months. HTN.
Scleroderma dx'd only 15 years ago (which is weird, right).
Hgb 8, bicarb normal, PLT normal.
On ACE inhibitor, BB, ASA, Plavix (for the popliteal stent) last 2 days ago.
Last TTE from 3 months ago shows EF 60%, moderate TR, RVSP = 66 assuming CVP = 15, RV function OK, otherwise normal.
CXR looks hyperexpanded but clear.
Exam -- frail and moribund, somnolent, only groans, but understands enough English to slowly follow commands. Gangrene just in the distal foot. Lungs clear but BS diminished. Wet weak cough.
Airway -- 1 fingerbreadth mouth opening. MP2. Full (implanted) dentition. Mouth opening is only maybe 3 FB from corner to corner. Short chin. Head ROM on neck limited.
On monitor in OR, HR = 130s (sinus tach), SpO2 = 74% room air

Any thoughts or changes in plan?
 
This lady is septic. The severe PHTN might be the least of concerns here. Neuraxial is out because of the Plavix.

First of all, this is an emergent intubation right there, if you can't bring that SpO2 up assisting her with mask ventilation. Might need just a touch of versed +/- propofol for induction. Glidescope. Careful positioning.

NC on high flow in the nose. LMAs ready for rescue ventilation. Difficult airway cart.

If expecting difficult ventilation, maintain spontaneous ventilation while taking a look with glidescope/transnasal fiberoptic. Consider awake FOI.

Pre-induction A-line if time permits. Post-induction central line. Fluids, pressors, antibiotics as needed, stat. Have platelets and PRBC ready.

Maintenance with sevo/isoflurane. Long-acting opiates (hydromorphone) as needed/tolerated.
 
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FFP said:
This lady is septic. The severe PHTN might be the least of concerns here.
Click to expand...

Infected but with only 1 SIRS criterion -- you werent privy to the normal WBC, RR, and T.
Regardless, had already been on vancomycin and pip/tazo x48h.
Does being septic influence the timing of the case, whether you do the case, or how you do the case?
 
Preop issues:

1. Hypoxia. Needs O2 on mask. If unable to maintain sats over 90% on NC, or concern for aspiration or hypercarbia, or other criteria, intubate.
2. HR of 130. After SpO2 is corrected, make sure that she's properly hydrated. If not SIRS/dehydration/hypoxia, consider correcting anemia, at least up to 10 g/dL.
3. Needs A-line for surgery, possibly central line, possibly pressors.
4. Stabilize in the ICU prior to surgery as much as possible.

Have to go...
 
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FFP said:
Here comes the $64K question: If the patient has pulmonary hypertension, would you place a PAC to monitor it intraop? 🙂
Click to expand...

Loooooooooooong time lurker, loooooooooonger time respectee of all that you fine Doctors do as a group. I'm sure Blade can post many PUBMED articles about PAC placements causing PA ruptures… like this one...

http://www.ncbi.nlm.nih.gov/pubmed/24332120

Seem to take place in frail, old ladies more often from what I've been taught. And the one time I saw a patient die on the table: frail, elderly lady who was getting PA pressures monitored by wedge. Question to OP: is that what you're getting at here?

Keep up the amazing posts!!! Sorry I'm late to the game --
SpongeMD
 
Noyac said:
3 20cc syringes of fentany. Pt gets some versed and then you start pushing the fentanyl. And you just deep pushing it until all 60cc are in. Then 2 days later the pt wakes up. It's perfect. What could be better?
Click to expand...



If you don't give them any more narcotics for the case I'm sure you can extubate at the end of the case. Fentanyl doesn't last long. You could even give 100mcg/kg and still extubate them 8 hrs into the icu.
 
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