Fun call case

[deleted171991]

---

Members don't see this ad.

Also, I wouldn't rule out a PE in this patient.

 

[OUAnesthesia]

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.

I agree but I think Bruin's point is also well taken. There are several ways to do this obviously and pushing 20-25 mcg/kg of fentanyl for this case obviously seems a bit absurd and totally unnecessary as there are other ways to provide a nice stable induction on a cardiac patient. That being said for cardiac cases I've never had an issue with the high dose narcotic. The first two patients are routinely extubated in the unit when we are dropping off our third case. Perhaps it is an old method but depending on the patient not always an unreasonable method. I agree that giving most people a truckload of benzo is probably not for the best and steer away from doing so. People may think it is antiquated but the hemodynamic response to induction and intubation is very favorable with that much narcotic. Sure you can do vital control with a plethora of medications but last I checked having your sternum cut open doesn't feel great so I personally don't understand the machismo mindset of saying you get through open hearts being stingy on a 10 cent short acting medication. Narcotics are a nice stable way of going to sleep with additions of small doses of gas/propofol/ketamine or whatever and in my experience do not routinely cause prolonged intubations in the unit following cardiac surgery. And yes...etomidate is crap.

 

[Hoya11]

I agree but I think Bruin's point is also well taken. There are several ways to do this obviously and pushing 20-25 mcg/kg of fentanyl for this case obviously seems a bit absurd and totally unnecessary as there are other ways to provide a nice stable induction on a cardiac patient. That being said for cardiac cases I've never had an issue with the high dose narcotic. The first two patients are routinely extubated in the unit when we are dropping off our third case. Perhaps it is an old method but depending on the patient not always an unreasonable method. I agree that giving most people a truckload of benzo is probably not for the best and steer away from doing so. People may think it is antiquated but the hemodynamic response to induction and intubation is very favorable with that much narcotic. Sure you can do vital control with a plethora of medications but last I checked having your sternum cut open doesn't feel great so I personally don't understand the machismo mindset of saying you get through open hearts being stingy on a 10 cent short acting medication. Narcotics are a nice stable way of going to sleep with additions of small doses of gas/propofol/ketamine or whatever and in my experience do not routinely cause prolonged intubations in the unit following cardiac surgery. And yes...etomidate is crap.

87 y/o lady, sats 74% ? When you have to get this fancy maybe its time to start talking to hospice.

If I HAD to, I would probably just do the spinal on plavix after discussion with family

 

[pgg]

If I HAD to, I would probably just do the spinal on plavix after discussion with family

True, looking at the risk/benefits ... what's the real risk of a spinal hematoma in a bedridden patient? She's not exactly a dancer for Cirque Du Soleil.

Though that said, I'd go for peripheral blocks on Plavix before a neuraxial block on Plavix.

 

[pgg]

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.

I wonder. If you start giving gargantuan doses of most anything metabolism shifts toward zero-order kinetics. Also, fentanyl is very fat soluble and there'd be a depot effect in that compartment. Try it and report back! 🙂

 

[urge]

I wonder. If you start giving gargantuan doses of most anything metabolism shifts toward zero-order kinetics. Also, fentanyl is very fat soluble and there'd be a depot effect in that compartment. Try it and report back! 🙂

I'm not talking out of textbooks. I'm talking out of real life experience. No matter how much fentanyl you give, everyone (not in shock) wakes up within 8 hrs in the icu.

I'm not recommending high dose narcotic induction to anyone. The only induction I recommend is Pent Sux Tube. But, saying that high dose narcotic induction leads to prolonged intubation is a misconception.

 

[pgg]

I'm not talking out of textbooks. I'm talking out of real life experience. No matter how much fentanyl you give, everyone (not in shock) wakes up within 8 hrs in the icu.

I'm not recommending high dose narcotic induction to anyone. The only induction I recommend is Pent Sux Tube. But, saying that high dose narcotic induction leads to prolonged intubation is a misconception.

You've given someone 100 mcg/kg of fentanyl before? As in, for a 100 kg standard-sized adult American male, 200 mL of the usual 50 mcg/mL fentanyl? 3 1/3 full 60 mL syringes? I'm in awe. 🙂 Of course no sane person would give a 70-100kg adult 100 mcg/kg (7-10 milligrams) of fentanyl for induction.

I believe you when you say everyone you've seen get a high dose narcotic induction wakes up within 8 hrs in the ICU ...

I just wonder, out of idle curiosity, aka mental masturbation, if someone who got the aforementioned absurd 100 mcg/kg of fentanyl really would wake up in 8 hours.

 

[deleted171991]

I just wonder, out of idle curiosity, aka mental masturbation, if someone who got the aforementioned absurd 100 mcg/kg of fentanyl really would wake up in 8 hours.

Does that include the 300 mg morphine-equivalent/day chronic pain people? 😀

 

[nap$ter]

True, looking at the risk/benefits ... what's the real risk of a spinal hematoma in a bedridden patient? She's not exactly a dancer for Cirque Du Soleil.

Though that said, I'd go for peripheral blocks on Plavix before a neuraxial block on Plavix.

this seems to come up often for me - i get an asa 4.5 patient for amputation of infected limb - on plavix.

i've done peripheral nerve blocks on plavix for these pts - if you block as distal as possible any hematoma is at worst going to give you a sensory neuropathy....

 

[fakin' the funk]

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

PA rupture is pretty rare. PAC placement is pretty rare. So you're talking about a rare complication of a relatively uncommon procedure. For me, the concern for PA rupture doesn't routinely figure into whether or not I place one.

 

[fakin' the funk]

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.

All valid concerns. (Incidentally, aren't you an attending?)

A few other random details:
Pt is DNR/DNI. Regardless, the CXR is clear so there is not an obvious reversible cause for hypoxia other than "the three P's" of PE, pulm HTN, PFO/ASD. Certainly pt is a setup for PE.
Pt has been withering away on the ward (not tele) for the last couple days.
Most recent hospitalist note remarks, "Tachycardia -- consider increasing beta blocker."
Goals of care from family members are a little murky, i.e., fervently against CPR or intubation, but very much for surgery, abx, IV fluids, artificial feeding, etc. Thankfully this is not my battle to fight this time.

 

[deleted162650]

Agree w/ Hoya on the SAB despite plavix. Epidural hematoma is a relatively rare complication especially compared to the risk of badness w/ a GA for all the reasons already mentioned. And like pgg mentioned, this bedridden lady now w/ 1 leg probably isn't gonna miss the use of her other leg that much.

If a tree falls in the woods . . .

And completely agree that a lowish dose isobaric spinal will have minimal hemodynamic impact. Have neo gtt running if you wanna be extra careful.

 

[fakin' the funk]

Pt was awake enough to cooperate with basic commands -- straighten your arm, open your mouth, etc.
In OR, on monitor. 1mg midazolam just to be a nice guy. O2 by nasal cannula got sats into mid-90's.
Topical atomized lidocaine to oropharynx w/ LMA MADgic (love that little device by the way) while asking pt to open mouth, then topical to hypopharynx/upper trachea with a little more lidocaine while asking patient to "pant" which she kind-of did.
Ovassapian airway in.
Awake FOI easy with a little jaw thrust from assistant, 6.5 ETT confirmed 4cm above carina, then 40mg propofol and turn on the desflurane. Had never used the Ovassapian airway before (only Williams or none) but I liked it.
Pt spontaneous w/ etCO2 in low-mid 40's whole case.
18g in EJ flows awesome.
Minimal blood loss w/ tourniquet. Not oozy despite plavix.
Multiple recruitment maneuvers given to eliminate atelectasis from the equation.
Extubated "awake" i.e. baseline preop mental status in OR.
To PACU, sats low-mid 90's on simple mask 10L.
CXR in PACU shows new RML/RLL opacity vs CXR 48 hours ago, for me concerning for aspiration PNA (not aspiration pneumonitis) given obvious wet cough and depressed mental status preop. Read by radiologist as "CHF vs pneumonitis." Thanks bro.
NT suctioned a couple times by PACU RN.
Talked case over with hospitalist -- pt is DNR/DNI, already on abx that cover HAP/aspiration PNA, to whatever degree mental status is related to sepsis it's already being treated with source control and abx, pt obviously deconditioned and moribund.
Dispo'd to tele.
7 days later, still languishing on ward. Palliative care on board. Likely to comfort care. Can't win 'em all.

 

[ranvier]

Thread a good read. Thanks for sharing this case.

 

[deleted171991]

All valid concerns. (Incidentally, aren't you an attending?)

A few other random details:
Pt is DNR/DNI. Regardless, the CXR is clear so there is not an obvious reversible cause for hypoxia other than "the three P's" of PE, pulm HTN, PFO/ASD. Certainly pt is a setup for PE.
Pt has been withering away on the ward (not tele) for the last couple days.
Most recent hospitalist note remarks, "Tachycardia -- consider increasing beta blocker."
Goals of care from family members are a little murky, i.e., fervently against CPR or intubation, but very much for surgery, abx, IV fluids, artificial feeding, etc. Thankfully this is not my battle to fight this time.

I apologize. Got caught in the interesting case, and forgot it was for residents only.

 

[nap$ter]

Pt was awake enough to cooperate with basic commands -- straighten your arm, open your mouth, etc.
In OR, on monitor. 1mg midazolam just to be a nice guy. O2 by nasal cannula got sats into mid-90's.
Topical atomized lidocaine to oropharynx w/ LMA MADgic (love that little device by the way) while asking pt to open mouth, then topical to hypopharynx/upper trachea with a little more lidocaine while asking patient to "pant" which she kind-of did.
Ovassapian airway in.
Awake FOI easy with a little jaw thrust from assistant, 6.5 ETT confirmed 4cm above carina, then 40mg propofol and turn on the desflurane. Had never used the Ovassapian airway before (only Williams or none) but I liked it.
Pt spontaneous w/ etCO2 in low-mid 40's whole case.
18g in EJ flows awesome.
Minimal blood loss w/ tourniquet. Not oozy despite plavix.
Multiple recruitment maneuvers given to eliminate atelectasis from the equation.
Extubated "awake" i.e. baseline preop mental status in OR.
To PACU, sats low-mid 90's on simple mask 10L.
CXR in PACU shows new RML/RLL opacity vs CXR 48 hours ago, for me concerning for aspiration PNA (not aspiration pneumonitis) given obvious wet cough and depressed mental status preop. Read by radiologist as "CHF vs pneumonitis." Thanks bro.
NT suctioned a couple times by PACU RN.
Talked case over with hospitalist -- pt is DNR/DNI, already on abx that cover HAP/aspiration PNA, to whatever degree mental status is related to sepsis it's already being treated with source control and abx, pt obviously deconditioned and moribund.
Dispo'd to tele.
7 days later, still languishing on ward. Palliative care on board. Likely to comfort care. Can't win 'em all.

cool.

fentanyl analgesia?

 

[Scotty_G]

For those who keep mentioning SAB on plavix; has anyone actually done this before?

 

[deleted59964]

yes I've done it. In a respiratory cripple - I don't remember the exact details but I/we thought the balance of risk favoured a SAB

 

[fakin' the funk]

cool.

fentanyl analgesia?

Gave 50mcg right before incision. Nothing else for the rest of the case. Pt acted comfortable in PACU. Didn't require pain rx otherwise until like 6 hours postop. A little surprising overall.

 

[fakin' the funk]

Agree w/ Hoya on the SAB despite plavix. Epidural hematoma is a relatively rare complication especially compared to the risk of badness w/ a GA for all the reasons already mentioned. And like pgg mentioned, this bedridden lady now w/ 1 leg probably isn't gonna miss the use of her other leg that much.

If a tree falls in the woods . . .

And completely agree that a lowish dose isobaric spinal will have minimal hemodynamic impact. Have neo gtt running if you wanna be extra careful.

Agree that this would be a reasonable option if others were awful/worse. Also agree that risk of spinal hematoma is CRAZY low (and overstated) even in pts on some degree of anticoag or antiplatelet rx.

 

[Scotty_G]

But how can you defend it with the ASRA guidelines if a hematoma occurs?

 

[fakin' the funk]

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.

Thanks for your post. You raised a number of good issues so I'll add some of my thinking here.

TTE findings are key here w/r/t scleroderma and pulm HTN. In this patient, although the PA pressures were estimated to be high (roughly 60/20), the measures of RV function (TAPSE, RVFAC, septal geometry) were all normal. Moderately elevated PA pressures with good RV function aren't really that big of a concern for me. It implies elevated PVR, which is totally what you'd expect in a patient with scleroderma and pulmonary microvascular disease.

Accordingly, the need for an arterial line wasn't that important for me. My anesthetic plan (awake FOI then slow inhalation indxn) is pretty "gentle" and not that prone to wild BP swings like an RSI would be. If there was another indication like needing to draw labs repeatedly, sure then, art line 'em up.

Obviously you didn't know that the airway exam was so $hitty. For me, the exam pointed ONLY to a FOI technique. Glidescope is not a good option for someone with limited mouth opening because it's a pretty bulky device. Most LMAs are fairly bulky too especially ones you'd be considering with a fiber like Fastrach or CookGas. So then for me the choice is asleep vs awake. I saw no downside to doing it awake in this patient -- patient was functionally "cooperatve" and there was no emergency really -- and it certainly is safer.

While I think being aggressive with nerve block catheters is great for some cases and some patients, these elderly frail patients don't really have a ton of pain with even painful-seeming types of surgeries, so I think it's prob overkill. Indeed, this pt only needed 50mcg fentanyl for 6 hours!

 

[deleted59964]

But how can you defend it with the ASRA guidelines if a hematoma occurs?

because risk of GA is > risk of hematoma

 

[deleted171991]

because risk of GA is > risk of hematoma

That is a tough defense to prove especially because, in case of a hematoma, the patient will need GA.

 

[Hoya11]

so in the end you put the 87 year old lady through a borderline awake FOB, and gave her a generous 50 of fentanyl for an AKA that shouldnt have been done in the first place.. then she dies one week later.. seems like one of the worst possible anesthestic outcomes to me

 

[risnwb]

so in the end you put the 87 year old lady through a borderline awake FOB, and gave her a generous 50 of fentanyl for an AKA that shouldnt have been done in the first place.. then she dies one week later.. seems like one of the worst possible anesthestic outcomes to me

What makes his AFOI borderline? Seems like he used a reasonable technique...

 

[urge]

You've given someone 100 mcg/kg of fentanyl before? As in, for a 100 kg standard-sized adult American male, 200 mL of the usual 50 mcg/mL fentanyl? 3 1/3 full 60 mL syringes? I'm in awe. 🙂 Of course no sane person would give a 70-100kg adult 100 mcg/kg (7-10 milligrams) of fentanyl for induction.

Over 100mcg/kg total during the case, yes. They still wake up within 8 hrs.

For induction once you are past 2mg everybody is asleep, so no real need to go over.

 

[Noyac]

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.

Yes you are correct. I was mostly just making fun of the whole cardiac induction.

 

[fakin' the funk]

so in the end you put the 87 year old lady through a borderline awake FOB, and gave her a generous 50 of fentanyl for an AKA that shouldnt have been done in the first place.. then she dies one week later.. seems like one of the worst possible anesthestic outcomes to me

I agree that the outcome is bad. Not really sure what "putting someone through" an awake FOB counts as, or how the outcome is attributable to the choice or delivery of anesthesia...but I'm listening.

 

[Hoya11]

I agree that the outcome is bad. Not really sure what "putting someone through" an awake FOB counts as, or how the outcome is attributable to the choice or delivery of anesthesia...but I'm listening.

it means that you rammed a tube through the trachea of an awake but dying hospice women, and then proceeded to not only let her get her leg cut off with no block of any kind, but also not provide her with enough narcotic pain medication.

take the patients comfort into your anesthetic plan, especially in this situation. Take a chance at DL or glidescope asleep, take a chance at a block on anticoagulation, take a chance with apnea to keep her comfortable with high dose narcotic. it sounds like she got a great anesthetic from the anesthesiologists perspective

 

[pgg]

take the patients comfort into your anesthetic plan, especially in this situation. Take a chance at DL or glidescope asleep, take a chance at a block on anticoagulation, take a chance with apnea to keep her comfortable with high dose narcotic. it sounds like she got a great anesthetic from the anesthesiologists perspective

An AFOI doesn't have to be a scary or painful experience, if it's not rushed.

It's not right to "take a chance" even on a Hospice patient having a palliative surgery.

I'll weigh risk/benefit of regional on Plavix; ASRA's guidelines are not absolute contraindications to regional on Plavix and were clearly never intended to be so. But taking risks with a non-emergent airway is another issue altogether.

If your elective AFOIs are an ordeal for patients you need to reassess your sedation, topicalization, and technique.

 

[OB1🤙]

I think the case was very well managed. Agree with pgg's comments.

If presented with this case myself, I may have found myself managing it the same. I may have done a spinal despite the plavix.

Or I may have done femoral/ high sciatic blocks, probably with some local in the fascia iliaca as well to try and get some LFC and obturator coverage. Then do the case with a fairly low dose propofol gtt, supplementing with nitrous or low dose ketamine if needed. I've done AKAs this way in sick folks before and it usually works well. Obviously this patient had an airway that makes this plan potentially dicey if you completely whiff on your blocks, and the low room air sat makes it a whole lot less favorable.

But the OP went with a KISS technique, and IMO conducted an elegant anesthetic. The ultimate outcome is unfortunate, and not unpredictable, but it's really not our call to make at that point. Our job is to conduct the case safely and ensure the patient's comfort, and the OP did that very well.

 

[psychbender]

it means that you rammed a tube through the trachea of an awake but dying hospice women, and then proceeded to not only let her get her leg cut off with no block of any kind, but also not provide her with enough narcotic pain medication.

take the patients comfort into your anesthetic plan, especially in this situation. Take a chance at DL or glidescope asleep, take a chance at a block on anticoagulation, take a chance with apnea to keep her comfortable with high dose narcotic. it sounds like she got a great anesthetic from the anesthesiologists perspective

Well, it sounds as though the patient was comfortable, with only a low dose of opioid, as evidenced by no further analgesic required for the first six hours post-op, and the patient maintaining spontaneous ventilation with ETCO2 in the 40s for the duration of the case (and, presumably, the patient not moving in response to stimuli with no relaxant on board). We can all argue that maybe this case should not have happened, and the patient instead placed on hospice care beforehand, but as everyone else is mentioning, we're not the primary team. That being said, I'd still have the talk with the family (whichever is actually present), about what exactly they plan to accomplish by going to the OR given her overall very poor medical state.

 

[nap$ter]

it means that you rammed a tube through the trachea of an awake but dying hospice women, and then proceeded to not only let her get her leg cut off with no block of any kind, but also not provide her with enough narcotic pain medication.

take the patients comfort into your anesthetic plan, especially in this situation. Take a chance at DL or glidescope asleep, take a chance at a block on anticoagulation, take a chance with apnea to keep her comfortable with high dose narcotic. it sounds like she got a great anesthetic from the anesthesiologists perspective

you make some pretty outlandish accusations/assumptions/suggestions here.

the case went well with a carefully executed minimalistic approach.

no one said anything about ramming tubes or inadequate pain control - not sure where you got that from.

"taking chances" wasn't necessary here.

 

[deleted171991]

so in the end you put the 87 year old lady through a borderline awake FOB, and gave her a generous 50 of fentanyl for an AKA that shouldnt have been done in the first place.. then she dies one week later.. seems like one of the worst possible anesthestic outcomes to me

Hindsight is 20/20.

I think the anesthesia team here did the most they could. The patient had a foot gangrene, was deconditioned and frail, but I don't really see why the surgery should not have been attempted, especially since gangrene was probably a contributing factor to her status. Her physical exam suggested a possibly difficult airway (in a patient with high risk for aspiration), so they did an awake fiberoptic, with proper sedation and topicalization (this was a lady with altered mental status, so she probably did not need much), and then a safe inhalational induction. They did not torture her with an A-line. They placed an EJ 18G that could double as a central line, if needed. Really good care here.

Did not need much analgesia on top of the inhalational anesthetics (not that surprising given the altered mental status). Woke up well. Was found with a CXR suggesting aspiration pneumonitis, probably the cause of the low preop SpO2, AMS etc., confirming again what a great idea the awake intubation was (so nobody can accuse the anesthesiologist that it happened during a difficult intubation).

I am the first to suggest hospice if I think there is not much benefit to gain from a surgery, besides postponing the inevitable. I don't think it was the case here. I think these guys did a great job on an ASA 4 patient. It's a pity she developed aspiration pneumonia (which tends to be bad in such a frail patient).

 

[fakin' the funk]

take a chance with apnea to keep her comfortable with high dose narcotic

Just wanna give you a little bit more rope here.

Which drugs and in what doses would you choose to do your high dose narcotic technique?

 

[Hoya11]

Just wanna give you a little bit more rope here.

Which drugs and in what doses would you choose to do your high dose narcotic technique?

how about more than 50mcg of fentanyl for someone getting their leg cut off? how about justifying why you didnt even attempt a regional, how about justifying your afoi? couldnt you put her to sleep at least to intubate her?

If i did this case I would have been embarrassed and actually felt a little bad for the person, not posted it on "fun call case" which is insanely insensitive. How do you think someone would wake up with 50mcg of fentanyl after an unblocked total knee? WOuld you believe it if i told you they had absolutely no pain after the 50mcg on induction? hard to believe. have mercy on your patients, its not always about keeping them alive.

 

[pgg]

Are you an attending?

Lots of these diabetic/vasculopath patients who are losing feet are 90% insensate to begin with. 50 mcg of fentanyl might be just fine.

I did a leg I&D in an 80 yo last night with zero opiate. The only reason he needed anesthesia at all was because he was demented and combative when awake. He got a grand total of 40 mg of ketamine and 60 mg propofol throughout the case and that's it.

 

[nap$ter]

how about more than 50mcg of fentanyl for someone getting their leg cut off? how about justifying why you didnt even attempt a regional, how about justifying your afoi? couldnt you put her to sleep at least to intubate her?

If i did this case I would have been embarrassed and actually felt a little bad for the person, not posted it on "fun call case" which is insanely insensitive. How do you think someone would wake up with 50mcg of fentanyl after an unblocked total knee? WOuld you believe it if i told you they had absolutely no pain after the 50mcg on induction? hard to believe. have mercy on your patients, its not always about keeping them alive.

 

[Southpaw]

I'm not questioning FTF's technique or decisions, but Hoya11 does make some sense. This isn't a 'fun call case'. It's a patient who had no business being in the OR in the first place, especially for an AKA (preop foot gangrene???).

 

[Colbare]

I'm not questioning FTF's technique or decisions, but Hoya11 does make some sense. This isn't a 'fun call case'. It's a patient who had no business being in the OR in the first place, especially for an AKA (preop foot gangrene???).

Would this be a situation where the anesthesiologist's opinion about whether it's right to perform the operation be considered? Or does anesthesia just make the call of whether the patient can get through it safely and be reasonably comfortable?

Assuming the surgeon has already discussed the risks/benefits of performing it with the family and they are designated to make decisions and want to go ahead.. then it seems like the anesthesiologists role at that point is to say yes or no this patient will most likely survive and most likely not have complications related to surgery post op.

It sounds like her bad outcome was related to a preoperative complication. The overall end result isn't fun, but I think the purely anesthetic part of her care is valuable/fun to learn about

 

[Noyac]

Would this be a situation where the anesthesiologist's opinion about whether it's right to perform the operation be considered? Or does anesthesia just make the call of whether the patient can get through it safely and be reasonably comfortable?

Assuming the surgeon has already discussed the risks/benefits of performing it with the family and they are designated to make decisions and want to go ahead.. then it seems like the anesthesiologists role at that point is to say yes or no this patient will most likely survive and most likely not have complications related to surgery post op.

It sounds like her bad outcome was related to a preoperative complication. The overall end result isn't fun, but I think the purely anesthetic part of her care is valuable/fun to learn about

It's always difficult to address these issues at the time of surgery. What seems to work best is to take them thru a peer review process.

 

[Southpaw]

It sounds like her bad outcome was related to a preoperative complication. The overall end result isn't fun, but I think the purely anesthetic part of her care is valuable/fun to learn about

Discussing the case does have value and is fun to a degree, especially for students and residents. I don't mean to be a curmudgeon or second guess another attending (I'm 1.5 years into private practice myself, and do my best to keep my head down at work and make no waves).

This is a tough case; no way around it. FTF did the best he could. Noyac is right, in the real world these issues are difficult. If you verbalize your concerns to the surgeon (why AKA for distal foot gangrene in an exceedingly sick, frail lady who isn't septic? why are we doing this case after hours? what's up with a room SpO2 of 74%?) then your only recourse is a peer review process.

 

[pd4emergence]

it means that you rammed a tube through the trachea of an awake but dying hospice women, and then proceeded to not only let her get her leg cut off with no block of any kind, but also not provide her with enough narcotic pain medication.

take the patients comfort into your anesthetic plan, especially in this situation. Take a chance at DL or glidescope asleep, take a chance at a block on anticoagulation, take a chance with apnea to keep her comfortable with high dose narcotic. it sounds like she got a great anesthetic from the anesthesiologists perspective

how about more than 50mcg of fentanyl for someone getting their leg cut off? how about justifying why you didnt even attempt a regional, how about justifying your afoi? couldnt you put her to sleep at least to intubate her?

If i did this case I would have been embarrassed and actually felt a little bad for the person, not posted it on "fun call case" which is insanely insensitive. How do you think someone would wake up with 50mcg of fentanyl after an unblocked total knee? WOuld you believe it if i told you they had absolutely no pain after the 50mcg on induction? hard to believe. have mercy on your patients, its not always about keeping them alive.

I don't know if you missed the post earlier with her airway exam, but it was pretty terrible. She has sclerodema, almost no neck ROM, a small mouth, and very poor mouth opening. She also is hypoxemic. To me the decision tree consists of do the case yes or no? Unfortunately for us, we can discuss, strongly suggest, beg, plead, offer sexual favors, but at the end of the day, if the surgeon calls it an emergency you as the anesthesiologist are kinda stuck. I may have gotten the wrong impression but from her vitals she looked rather septic or at least possibly septic. She tachycardic, she's hypoxic. My guess is the surgeon is gonna call it an emergency. He/she is gonna say its the foot causing the problems. The surgeon is also going to decide what procedure to do also AKA vs. BKA. So, unfortunately for this lady the case is gonna get done. A block or spinal (even with the plavix) are good options in somebody who doesn't already look like they are headed for intubation but this lady looks like she is headed that way for sure. I think dealing with her airway preemptively is a perfectly reasonable option (and for me in this instance the preferred option). Unfortunately, with her airway exam she is at a very high risk of being very difficult and approaching impossible. You could put on your cowboy hat and sleep her and struggle and maybe get it in, or you could do a controlled awake FOI and have a lot more chance of being successful. The mouth opening here is key. It doesn't open. You are not gonna get an LMA in there. A nondisposable glidescope or CMAC may fit but you are not going to get anything else in there. This airway is gonna suck and in my opinion you make it worse by an induction. As for the narcotic issue, if she is not hurting then she doesn't need anymore. 87 yr olds don't need a whole lot.....

 

[epidural man]

how about more than 50mcg of fentanyl for someone getting their leg cut off? how about justifying why you didnt even attempt a regional, how about justifying your afoi? couldnt you put her to sleep at least to intubate her?

If i did this case I would have been embarrassed and actually felt a little bad for the person, not posted it on "fun call case" which is insanely insensitive. How do you think someone would wake up with 50mcg of fentanyl after an unblocked total knee? WOuld you believe it if i told you they had absolutely no pain after the 50mcg on induction? hard to believe. have mercy on your patients, its not always about keeping them alive.

Holy crap Hoya.

Calling it a "fun" case was hyperbole. How did you miss that?

Also, a controlled awake FOI is almost never the wrong answer. Getting an airway is the MOST important thing in any anesthetic case - and the safest is an awake attempt. We don't do them often because it takes a lot of effort on OUR PART and is usually overkill, but to criticize someone who felt like it was needed is baffling (from an anesthesiologist).

Finally, your point about the amount of opioids used is very antequated and misinformed, and completely opposite to that which seems to be true. More opioids the OP would have given intraoperatively would have equated to MORE pain post operatively. That has been shown time and time again. Intraoperative opioids DO NOT help post-operative pain, and likely make opioid requirements go up. Nociception under anesthesia does not equate to pain after anesthesia. Pain requires cognitive thought. Once congintive thought is established, it is often surprising how little people can actually hurt - even with a seemingly painful procedure.

 

[deleted171991]

Is this pain attending vs. pain attending?

 

[fakin' the funk]

Would this be a situation where the anesthesiologist's opinion about whether it's right to perform the operation be considered? Or does anesthesia just make the call of whether the patient can get through it safely and be reasonably comfortable?

Assuming the surgeon has already discussed the risks/benefits of performing it with the family and they are designated to make decisions and want to go ahead.. then it seems like the anesthesiologists role at that point is to say yes or no this patient will most likely survive and most likely not have complications related to surgery post op.

My approach to your question is this.

We see a lot of surgeries. We know who the good surgeons are, we know who the bad surgeons are, and we know what "they [surgeons] usually do" for different conditions. Our input can be quite valuable as to choosing the surgical procedure based on our knowledge of the patient, surgical, and anesthetic factors that are gonna go into play. Surgeons may know that X patient won't tolerate Y procedure (say, strict Jehovah's Witness being evaluated for a 10 level redo spine surgery) and they'll never schedule them for surgery. Or maybe they'll bring along a BMI 60 patient with advanced COPD for a robot prostatectomy -- in which our input (patient won't tolerate the position+insufflation) is invaluable. Or maybe the anesthesiologist sees a really marginal patient scheduled for a really major surgery, and their assessment of the risk of the procedure or their concerns about it is enough to make the surgeon think twice; this happens more commonly and more effectively between physicians who know each other well (personally).

That said, we don't know the unique surgical risks/benefits for every procedure nor do we actually perform it. I don't know why some of our surgeons do reverse total shoulders, others do normal. Additionally, we often meet the patient for the first time just moments before the procedure. The surgeon has met the patient -- almost always -- at least once before. So, generally speaking, we are in no place to agree with or disagree with the actual choice of surgical procedure (except for its implications as above) nor do we know the patient/family well.

 

[fakin' the funk]

This isn't a 'fun call case'. It's a patient who had no business being in the OR in the first place, especially for an AKA (preop foot gangrene???).

Whether or not you agree with my hyperbole / sarcasm in the choice of the word "fun," I find such cases fun. I like my job. I enjoy challenging cases as an anesthesiologist. It is a pleasure to use my training, knowledge, and skills to help patients survive the ordeal of surgery. I loved sick / hard cases during residency, and it's why I did ICU fellowship.

And yes you knuckleheads, I ALSO realize the sensitivity of the medical and ethical issues at hand.

 

[deleted162650]

I don't know why some of our surgeons do reverse total shoulders, others do normal.

Intact rotator cuff = normal total shoulder, blown out rotator cuff = reverse. 😉

 

[Ronin2258]

So why are we doing an AKA and not a BKA, again?

While BKA is better for rehabilitation, bad ABIs with an active gangrene may warrant going to an AKA. The BKA may not have enough blood supply to heal. More of a "cut until it bleeds," mindset.

Doing a few of those when I was still doing surgery, you have to go where the tissue has a best chance to heal. Even before the tourniquet went up, that below knee tissue is pretty poorly perfused. And they were pretty bloody gruesome.