Good Board Review Case

[sethco]

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Thought this would be a good change of pace. So as usual let's here from the residents/fellows their plan for this patient. Treat this as an answer you are giving to a board examiner.

You are called over to a hospital in the sticks for an emergent CME, but have no info on the patient. Your curiosity is obviously high already. This hospital does about 200 cardiac cases a year, but nothing outside of the standard valves, CABG, LAA ligation (I.e. No ECMO service).

You see the patient and review of the chart. Reveals a 42 y/o female in otherwise good health up until couple weeks ago. She notes a recent URI/Sinusitis that she saw her PCP for and was prescribed antibiotics. Initially helped her symptoms, but over the past couple of days, she has noted b/l upper extremity, neck, and facial swelling. She also admits to dyspnea in the supine position. All labs are otherwise normal. Physical exam shows obvious facial, neck, and arm swelling. MP 2 with neck swelling to the point where landmarks could not be felt, but good CROM. Lungs are clear and normal cardiac exam. CT chest/neck shows a 7 X 7 cm mass compressing the SVC and trachea, but not causing complete obliteration. Pulmonary/CCM has already seen the patient and don't feel that they can get an answer with Bronchoscopy, so CT surgeon wants to do a diagnostic CME, so we can determine if urgent radiation therapy is needed. She currently has two upper extremity peripheral IVs in place and is sitting bolt upright, but not in current distress, in preop holding.

Tell me about your intraop and postop plans

 

[Arch Guillotti]

You are called over to a hospital in the sticks for an emergent CME

ACE or SEE?😉

 

[Ronin786]

I'll take a stab. Obviously the big elephant in the room is going to be the airway and hemodynamics post-induction. She's sitting upright currently but I want to see how she does when she's laid flat. Are her hemodynamics going to tolerate being supine in addition to the fact that she has dyspnea supine.

My plan would be:
1) Pre-induction arterial line, taking a good look at the tracing while upright and supine. Also T&C 2-4 units of PRBCs.
2) Two good working PIVs should be enough for immediate resuscitation during induction, furthermore, placement of anything in the neck might be difficult in this patient if she can't lay flat.
3) I'd plan for an awake FOI with an armored tube. That way I maintain spontaneous respiration and also avoid having to place her supine before securing the airway.
4) After induction w/some sevo and ketamine after securing the airway, I'd probably place a neck line on the opposite side of the SVC obstruction.
5) If SHTF and/or I can't secure the airway, I'm going to have CT surgery place wires in the groin and go on pump.

 

[dragonark]

I'll take a stab. Obviously the big elephant in the room is going to be the airway and hemodynamics post-induction. She's sitting upright currently but I want to see how she does when she's laid flat. Are her hemodynamics going to tolerate being supine in addition to the fact that she has dyspnea supine.

My plan would be:
1) Pre-induction arterial line, taking a good look at the tracing while upright and supine. Also T&C 2-4 units of PRBCs.
2) Two good working PIVs should be enough for immediate resuscitation during induction, furthermore, placement of anything in the neck might be difficult in this patient if she can't lay flat.
3) I'd plan for an awake FOI with an armored tube. That way I maintain spontaneous respiration and also avoid having to place her supine before securing the airway.
4) After induction w/some sevo and ketamine after securing the airway, I'd probably place a neck line on the opposite side of the SVC obstruction.
5) If SHTF and/or I can't secure the airway, I'm going to have CT surgery place wires in the groin and go on pump.

A few followup questions...as a fake board examiner style followup... I apologize if this counts as thread jacking from the OP...
Patient crashes on induction. How are your PIVs used in resuscitating the patient? Are you giving volume or medications? If you don't see a response to either, what do you do next?
What side of the neck would be opposite the SVC obstruction?
How long does it take to place wires in the groin and go on pump? Where are the wires going? Assuming that the patient is in complete cardiopulmonary collapse, how can you differentiate between an arterial and venous vessel?

Edit: Sorry took about ECMO as I just reread the part in the prompt about NO ECMO

 

[sigrhoillusion]

Thought this would be a good change of pace. So as usual let's here from the residents/fellows their plan for this patient. Treat this as an answer you are giving to a board examiner.

You are called over to a hospital in the sticks for an emergent CME, but have no info on the patient. Your curiosity is obviously high already. This hospital does about 200 cardiac cases a year, but nothing outside of the standard valves, CABG, LAA ligation (I.e. No ECMO service).

You see the patient and review of the chart. Reveals a 42 y/o female in otherwise good health up until couple weeks ago. She notes a recent URI/Sinusitis that she saw her PCP for and was prescribed antibiotics. Initially helped her symptoms, but over the past couple of days, she has noted b/l upper extremity, neck, and facial swelling. She also admits to dyspnea in the supine position. All labs are otherwise normal. Physical exam shows obvious facial, neck, and arm swelling. MP 2 with neck swelling to the point where landmarks could not be felt, but good CROM. Lungs are clear and normal cardiac exam. CT chest/neck shows a 7 X 7 cm mass compressing the SVC and trachea, but not causing complete obliteration. Pulmonary/CCM has already seen the patient and don't feel that they can get an answer with Bronchoscopy, so CT surgeon wants to do a diagnostic CME, so we can determine if urgent radiation therapy is needed. She currently has two upper extremity peripheral IVs in place and is sitting bolt upright, but not in current distress, in preop holding.

Tell me about your intraop and postop plans

"currently has two upper extremity peripheral IVs"

Maybe this is academic dogma, but always thought that with SVC syndrome you try to avoid upper extremity IVs. Also, not sure what a neck line "opposite of the obstruction" would provide considering the obstruction is downstream of both neck veins if it's bilateral swelling.

Agree with others on awake FOI with armored tube, attempting to maintain SV and using ketamine and having an A-line. Also would have ENT available, rigid bronch, the usual. And although ECMO isn't available, I'm assuming if there's a CT surgeon doing this case, and they do "normal" cardiac cases, they would have the ability to go on pump in worst case scenario. Then again, having a backup plan to crash onto bypass is never the greatest thing...

 

[Ronin786]

Sorry, I confused SVC with subclavian. In that case I'm putting in a femoral cordis before induction, along with a peripheral IV elsewhere in the lower extremity. Resuscitation is going to be mainly volume and epinephrine, I want to increase my CVP and overcome the SVC obstruction. If the patient is crashing then my surgeon can perform a cutdown and cannulate arterially and venously or use my cordis as a guide while I resuscitate with the PIV.

Also if possible I'm going to place my patient in the left lateral position to help relieve some of that obstruction.

A few followup questions...as a fake board examiner style followup... I apologize if this counts as thread jacking from the OP...
Patient crashes on induction. How are your PIVs used in resuscitating the patient? Are you giving volume or medications? If you don't see a response to either, what do you do next?
What side of the neck would be opposite the SVC obstruction?
How long does it take to place wires in the groin and go on pump? Where are the wires going? Assuming that the patient is in complete cardiopulmonary collapse, how can you differentiate between an arterial and venous vessel?

Edit: Sorry took about ECMO as I just reread the part in the prompt about NO ECMO

 

[Robotic Wis-Hipple]

I don't see CT surgeons that do simple hearts with no ECMO in house being the types to throw in peripheral bypass lines post "SHTF" by cutdown or otherwise. But if that's my backup I'd put femoral arterial and venous lines in pre-induction using catheters that can take the peripheral cannula wires (check what kits they use). Planning for those lines potentially being hijacked for support I'd want a good lower extremity PIV as well. Of course, if she can't lie flat all these groin lines aren't run of the mill lines to place either, I've never been forced to do groin lines in steep reverse but I guess it can't be too bad.

Couple of questions;

Why does this case need to be done in the sticks?

How are her hemodynamics on exam?

How "compressed" is the trachea on CT? I.e. Will it even take an ETT adequate sized to accommodate a bronchoscope?

 

[Planktonmd]

ACE or SEE?😉

I don't know why people don't just say mediastinoscopy!

 

[Planktonmd]

There is 2 issues with this case:
1- Since the patient is having dyspnea in the supine position, and there is clear vascular compression with a huge lesion, this should be taken seriously. The possibility of airway and hemodynamic collapse on induction of GA is real here.
2- Since the procedure is going to be only diagnostic and the mass effects will not be relieved by surgery, we also have to have a clear plan on how we return this patient to the pre-op baseline and eventually extubate.
Lower extremity IV and Arterial lines are definitely a good idea, then followed by mild sedation, good topical anesthesia and airway blocks, then gentle awake fiberoptic intubation with the head elevated 30-45 degrees.
Keep the patient breathing spontaneously and titrate Ketamine, vapor with little opiate. start lowering the head of the bed while watching the aline and stop if you see sudden decrease of BP, that's going to be the position the surgery will have to be done at, but if the surgeon can not do it with the head elevated, then bypass is the only option.
No muscle relaxants, minimal opiates and maintain spontaneous ventilation with some pressure support.
at the end put the patient in the sitting position and extubate when ready.

 

[Noyac]

followed by mild sedation, good topical anesthesia and airway blocks, then gentle awake fiberoptic intubation with the head elevated 30-45 degrees.
.

Good plan.
For the others, how would you go about topicalizing the airway? What airway blocks? Remember this pt has a lot of edema/swelling to the point that landmarks can't be appreciated.

 

[bigdan]

Seth -

I'm interested to hear how this case turned out.

My preop plan includes finding out if the hospital has a radiologist that can get this super-urgent sample of cells with a US or CT guided biopsy.

 

[sethco]

I don't know why people don't just say mediastinoscopy!

What can I say...We love acronyms in the military

 

[Noyac]

What can I say...We love acronyms in the military

I hate em!

 

[sethco]

Seth -

I'm interested to hear how this case turned out.

My preop plan includes finding out if the hospital has a radiologist that can get this super-urgent sample of cells with a US or CT guided biopsy.

How's it going Dan? Long time, no hear. Going to SCA this year? We're making plans right now for it.

Anyway, the case went pretty uneventfully. Just thought the presentation would be the best part for the residents. Good practice for boards and explaining their thought processes.

I let more people put in their two cents before I say how the case went. Couple of thoughts...

1) While this hospital isn't a tertiary care center or a big academic hospital, this patient was actually transferred from an OSH. CT surgery is available, CPB is available, 20 bed ICU is available, radiation oncology is available, etc. However, as said before, ECMO not an option

2) Pt had two peripheral IVs in the upper extremities. While they may work now, can these really be counted on?

3) As Noyac referred above, what process would everyone use for topicalization? Landmarks could not be palpated. What meds do you want to use for sedation?

4) Pt is currently hemodynamically stable without any drips. Hence, they brought her down to preop holding. The mass is causing compression of the trachea where it seems to be about 1/3 original size. No stridor heard in upright or supine position.

5) CT surgeon note made comment that Mediastinoscopy is contraindicated in the presence of SVC Syndrome, but conceded to the fact that there were no other options for diagnostic purposes according to Pulm. More on this later...

6) There are a couple of hospitals that I go to where they do not stock Ketamine. Wouldn't you know it, this is one of them. Love the drug, but not available. What would you use instead?

More to come...

 

[Shimmy8]

re: Ketamine

Precedex with no loading dose, lots of coaching before hand.

 

[Noyac]

Mediastinal biopsies in a pt with SVC syndrome!

 

[polar403]

How's it going Dan? Long time, no hear. Going to SCA this year? We're making plans right now for it.

Anyway, the case went pretty uneventfully. Just thought the presentation would be the best part for the residents. Good practice for boards and explaining their thought processes.

I let more people put in their two cents before I say how the case went. Couple of thoughts...

1) While this hospital isn't a tertiary care center or a big academic hospital, this patient was actually transferred from an OSH. CT surgery is available, CPB is available, 20 bed ICU is available, radiation oncology is available, etc. However, as said before, ECMO not an option

2) Pt had two peripheral IVs in the upper extremities. While they may work now, can these really be counted on?

3) As Noyac referred above, what process would everyone use for topicalization? Landmarks could not be palpated. What meds do you want to use for sedation?

4) Pt is currently hemodynamically stable without any drips. Hence, they brought her down to preop holding. The mass is causing compression of the trachea where it seems to be about 1/3 original size. No stridor heard in upright or supine position.

5) CT surgeon note made comment that Mediastinoscopy is contraindicated in the presence of SVC Syndrome, but conceded to the fact that there were no other options for diagnostic purposes according to Pulm. More on this later...

6) There are a couple of hospitals that I go to where they do not stock Ketamine. Wouldn't you know it, this is one of them. Love the drug, but not available. What would you use instead?

More to come...

2) Not necessarily if the mass causes hemodynamic compromise by compressing the SVC, get access below the left atrium. Ideally 8.5 French in the femoral so you can wire it out if necessary for bypass, as mentioned above. Peripheral LE IV as back-up so if they need to go on bypass you still have access. Talk with surgeon and consider placing a wire in femoral artery.

3) With no palpable landmarks, just use 4% lidocaine aerosolized and then topicalize with 4% lidocaine with a malleable atomizer attached to a syringe. Take your time. Do this while awake or minimal sedation.. which leads to...

6) Plenty of options for sedation. Avoid opioids as much as possible to keep spontaneous ventilation. It is all about titration easing it in. Time is on your side if they can tolerate sitting. Precedex preferably (however recent studies show it causes respiratory depression which is contrary to what everyone is taught), propofol is an option as is midazolam. Start low, go slow. You can always give more. If you use midzolam, have flumazenil available. HOWEVER, with good topicalization you don't necessarily need sedation if the patient can tolerate it.

and back to

5) Consult interventional radiologist to see if there is a possibility of ultrasound guided biopsy in the OR. Other option could be fluoro-guided biopsy in the OR. CT guided biopsy is likely not an option due to need for the patient to be supine for the scanner (however they did tolerate a scan in the first place -- but CT guided biopsy requires being supine for longer).

4) The CT was likely done while supine so you can see without sedation how much compression the mass effect has lying flat. There is always the option of great topicalization and awake fiberoptic with no sedation while in supine position to make sure ETT is past compression or for initial look with FOS. However, can estimate where it is with a look with pedi FOS while supine or by CT (plenty of distance from carina, etc.).

 

[Arch Guillotti]

6) Plenty of options for sedation. Avoid opioids as much as possible to keep spontaneous ventilation. It is all about titration easing it in. Time is on your side if they can tolerate sitting. Precedex preferably (however recent studies show it causes respiratory depression which is contrary to what everyone is taught), propofol is an option as is midazolam. Start low, go slow. You can always give more. If you use midzolam, have flumazenil available. HOWEVER, with good topicalization you don't necessarily need sedation if the patient can tolerate it.

I would have no hesitation using fentanyl as long as it is given judiciously and not mixed in with a bunch of other crap. I wouldn't give a drop of propofol.

 

[deleted171991]

Actually precedex is a great drug for these cases. And almost everything can cause respiratory depression if overdosed; one shouldn't need a lot of sedation for an awake intubation. Unfortunately droperidol is not available anymore.

 

[polar403]

I would have no hesitation using fentanyl as long as it is given judiciously and not mixed in with a bunch of other crap. I wouldn't give a drop of propofol.

Agreed. Stick to one. I would prefer to do it completely awake with good topicalization. Would prefer precedex (over other sedation options). Would like to avoid propofol altogether however if it's the only option and can't tolerate topical only then used extremely judiciously (and not something on oral boards).

 

[Noyac]

In my experience, If the pt is anxious then preceded isn't all that good.
I wouldn't have any issue using propofol in this case but it isn't necessary either. Ketamine and some narcs, maybe remi, would also be an option.
So if you get where I'm coming from, it doesn't really matter what you use to sedate as long as you know how to use it and how to get out of trouble.

Topicalization of the airway is important obviously. My approach would be to start with some glyco and then follow with viscous lidocaine. Next I would consider nebulized lido but I find this to be less than impressive. Then once the oropharynx is sufficiently numb I would proceed with a transtracheal. If I can't locate the trachea then I would use the US. But I would be very persistent in this task. Pts with a good transtracheal will tolerate an ETT in their trachea with very little objection. If I am really concerned that I will struggle then I would go with a nasal FOI. In that case I would also topicalization the nares. But I don't want any bleeding.

 

[polar403]

In my experience, If the pt is anxious then preceded isn't all that good.
I wouldn't have any issue using propofol in this case but it isn't necessary either. Ketamine and some narcs, maybe remi, would also be an option.
So if you get where I'm coming from, it doesn't really matter what you use to sedate as long as you know how to use it and how to get out of trouble.

Topicalization of the airway is important obviously. My approach would be to start with some glyco and then follow with viscous lidocaine. Next I would consider nebulized lido but I find this to be less than impressive. Then once the oropharynx is sufficiently numb I would proceed with a transtracheal. If I can't locate the trachea then I would use the US. But I would be very persistent in this task. Pts with a good transtracheal will tolerate an ETT in their trachea with very little objection. If I am really concerned that I will struggle then I would go with a nasal FOI. In that case I would also topicalization the nares. But I don't want any bleeding.

Agree with above. Precedex combined with an appropriately titrated amount of midazolam helps in anxious patients if precedex not doing the job correctly.

I forgot to mention the glyco. Didn't mention ketamine because he said it wasn't available at his facility. Nebulized lidocaine allows you to help topicalize prior to OR and on the way back (also pre-oxygenates). Just an adjunct to everything else.

 

[Arch Guillotti]

Then once the oropharynx is sufficiently numb I would proceed with a transtracheal. If I can't locate the trachea then I would use the US.

Ultrasound? Are you serious? How often have you done this before?

Why not just squirt theough the end of the beonchoscope?

 

[Noyac]

Ultrasound? Are you serious? How often have you done this before?

Why not just squirt theough the end of the beonchoscope?

I have not needed to do it this way but I have looked with the US and the trachea is super easy to find if that's what you are asking.

I don't like to squirt through the scope as much because it takes a little while to get good topicalization but I will agree that it works fine. It's just not my approach.

Basically, I always do a transtracheal because not only doesn't it topicalization the trachea but it gets the cords well also when they cough it back up on the cords. And more importantly, it tells me where the trachea actually is. In cases where the airway could be lost (i.e: tumor obstructing the airway or hematoma or abscess etc) I want to know where the trachea is in case I need to get to it from the neck. On occasion I will actually access the trachea with an 18- 16g angiocath, slide it off into the trachea and then inject through the catheter. Then leave it in place to either entrain O2 or to hook up the jet ventilator in dire circumstances.

 

[Ronin786]

Ultrasound? Are you serious? How often have you done this before?

Why not just squirt theough the end of the beonchoscope?

I'm not a fan of squirting through the bronchoscope. If I see the vocal cords, I much prefer to push my ETT through them than have the patient cough and go down again. Obviously depends on how great my landmarks are.

 

[Planktonmd]

Ultrasound? Are you serious? How often have you done this before?

Why not just squirt theough the end of the beonchoscope?

That squirting through the scope thing they keep telling people to do results most of the time in the patient coughing, getting restless, and you losing your perfect view!

 

[deleted171991]

That squirting through the scope thing they keep telling people to do results most of the time in the patient coughing, getting restless, and you losing your perfect view!

Maybe they are squirting too much.

 

[pgg]

Actually precedex is a great drug for these cases. And almost everything can cause respiratory depression if overdosed; one shouldn't need a lot of sedation for an awake intubation. Unfortunately droperidol is not available anymore.

Next AFOI that I do I'm going to try Haldol.

 

[deleted171991]

Next AFOI that I do I'm going to try Haldol.

Apparently it's not as good as Droperidol for this, but in a pinch I would probably use it.

 

[CaliDreamin4Life]

How does this case end?

Sent from my SM-N910V using SDN mobile

 

[Noyac]

Apparently it's not as good as Droperidol for this, but in a pinch I would probably use it.

What was the combination of droperidol and fentanyl called? I can't remember.

 

[Libertas]

.....what does a diagnostic CME stand for???

 

[deleted171991]

What was the combination of droperidol and fentanyl called? I can't remember.

Neuroleptanesthesia?

 

[deleted171991]

How does this case end?

Sent from my SM-N910V using SDN mobile

The anesthesiologist clicks on Anesthesia End.

 

[deleted171991]

.....what does a diagnostic CME stand for???

Cervical Mediastinal Exploration.

 

[Planktonmd]

What was the combination of droperidol and fentanyl called? I can't remember.

Innovar!
It was used also as a pre-op medication and provided excellent sedation and anxiolysis, but occasionally a patient would get a panic or fear reaction and would refuse to go ahead with surgery.

 

[dhb]

Innovar!
It was used also as a pre-op medication and provided excellent sedation and anxiolysis, but occasionally a patient would get a panic or fear reaction and would refuse to go ahead with surgery.

That's because it didn't provide anxiolysis... had a patient freak out on drop mid c-section , bought herself a tube.

 

[Planktonmd]

That's because it didn't provide anxiolysis... had a patient freak out on drop mid c-section , bought herself a tube.

You know... I always wondered about that... do neuroleptics really provide anxiolysis or do they they just suppress your ability to act in response to anxiety?

 

[sethco]

OK, so here is how it went down. Discussed case with CT surgeon/Pulm about whether this could be done with either CT guided biopsy or Transtracheal biopsy through Bronchoscopy. Radiologist declinied because he did not feel comfortable doing this. CT Surgeon and Pulmonologist both agreed that Bronch would be attempted but doubted that it would give an answer, so Mediastinoscopy would follow if no answer. Pulm refusing to complete the procedure without an ETT in place. I tell him Ok, but I reserve the right to abort the procedure if she becomes unstable. Perfusionist is available, but I told them not to prime the pump.

Meet the patient in preop holding and explain the plan. Give her 0.3 mg Glyco and 2 mg Midazolam. Awake femoral arterial line/central line prior to induction, which was well tolerated. Give 1 additional mg Midazolam and 50 cg Fentanyl. Proceed with topicalizing with Viscous 2% Lidocaine on tongue depressor. Pt cooperative where she is holding the tongue depressor. I did not do a transtracheal block, but admit I may have been able to with U/S. Instead, I feel I am quite good with Bronchoscopy where I did not mind getting a good view, spraying the cords and removing the Bronch so the patient could "recover". Some may think this to be an unnecessary step and that's ok. I sprayed the vocal cords with 100 mg Lidocaine and then a minute later got another great view of the cords. Advanced an 7.5 Armored ETT in position, confirmed EtCO2, and turned on the Sevo. I also gave an additional 50 mcg Fentanyl and 25 mg Propofol at this point. this was enough to settle her out while maintaining spontaneous ventilation. All of this was performed in a steep reverse trendelenberg position. Hemodynamic stability was maintained and we proceeded with the Bronchoscopy. Samples were taken just above the carina. CT surgeon goes to converse with the pathologists, who says we have enough for an answer. So I turned off the sevo until she was awake and deflated the ETT cuff to make sure there was still a leak (This may have been an unnecessary step, but it made me more comfortable) and then she was extubated and transported to ICU (after a brief PACU stay) for observation.

Like I said, case was pretty uneventful. However, it is the patient presentation and the Anesthetic plan that makes you a consultant. Describing your thought process and the pharmacology/physiology behind it, along with backup/contingency plans is paramount in your oral board performance and your clinical career

 

[Planktonmd]

OK, so here is how it went down. Discussed case with CT surgeon/Pulm about whether this could be done with either CT guided biopsy or Transtracheal biopsy through Bronchoscopy. Radiologist declinied because he did not feel comfortable doing this. CT Surgeon and Pulmonologist both agreed that Bronch would be attempted but doubted that it would give an answer, so Mediastinoscopy would follow if no answer. Pulm refusing to complete the procedure without an ETT in place. I tell him Ok, but I reserve the right to abort the procedure if she becomes unstable. Perfusionist is available, but I told them not to prime the pump.

Meet the patient in preop holding and explain the plan. Give her 0.3 mg Glyco and 2 mg Midazolam. Awake femoral arterial line/central line prior to induction, which was well tolerated. Give 1 additional mg Midazolam and 50 cg Fentanyl. Proceed with topicalizing with Viscous 2% Lidocaine on tongue depressor. Pt cooperative where she is holding the tongue depressor. I did not do a transtracheal block, but admit I may have been able to with U/S. Instead, I feel I am quite good with Bronchoscopy where I did not mind getting a good view, spraying the cords and removing the Bronch so the patient could "recover". Some may think this to be an unnecessary step and that's ok. I sprayed the vocal cords with 100 mg Lidocaine and then a minute later got another great view of the cords. Advanced an 7.5 Armored ETT in position, confirmed EtCO2, and turned on the Sevo. I also gave an additional 50 mcg Fentanyl and 25 mg Propofol at this point. this was enough to settle her out while maintaining spontaneous ventilation. All of this was performed in a steep reverse trendelenberg position. Hemodynamic stability was maintained and we proceeded with the Bronchoscopy. Samples were taken just above the carina. CT surgeon goes to converse with the pathologists, who says we have enough for an answer. So I turned off the sevo until she was awake and deflated the ETT cuff to make sure there was still a leak (This may have been an unnecessary step, but it made me more comfortable) and then she was extubated and transported to ICU (after a brief PACU stay) for observation.

Like I said, case was pretty uneventful. However, it is the patient presentation and the Anesthetic plan that makes you a consultant. Describing your thought process and the pharmacology/physiology behind it, along with backup/contingency plans is paramount in your oral board performance and your clinical career

Good job.

 

[deleted171991]

Good job.

How can you say that? He didn't do a transtracheal block. 😛

 

[Noyac]

How can you say that? He didn't do a transtracheal block. 😛

Exactly!!!

I would have failed him if I was the examiner.


See you next year, sucker.

 

[Noyac]

In all seriousness, great job.

I often wonder if the other physicians ( CT surg, Pulmonary, etc) really understand everything that you did here. You made it look so freaking easy in their eyes. I'm sure the risk and importance of everything you did was lost on them. But that's why we have DOCTORS still doing anesthesia.

Btw, we will do those bronchoscopies (EBUS) with an LMA on occasion. This also may have been an option. Just as a secondary approach. More than one way to skin a cat.

 

[Robotic Wis-Hipple]

Just gonna point out I nailed the awake fem lines in steep reverse trendelenberg. 😉 What lines specifically did you place if I may ask? Cordis with a 5Fr?

These cases always have their proponents on opposite sides; one side goes full bore uber conservative with all awake lines and everything at the ready while the other side argues minimal anesthesia minimal stimulation and just know what to do when things go south. At this stage in my career (not actually started yet) I fall on the full bore side but I can see the argument for minimalism and not "crying wolf" everytime.

 

[Arch Guillotti]

Btw, we will do those bronchoscopies (EBUS) with an LMA on occasion. This also may have been an option. Just as a secondary approach. More than one way to skin a cat.

LMA on mediastinoscopy with tracheal deviation and a difficult airway?

 

[Arch Guillotti]

That squirting through the scope thing they keep telling people to do results most of the time in the patient coughing, getting restless, and you losing your perfect view!

You are right. Instead you should just shove the bronchoscope in and make them cough like crazy while you attempt to examine the trachea.😉

 

[Noyac]

LMA on mediastinoscopy with tracheal deviation and a difficult airway?

Why not? They are breathing spontaneously. Are you afraid of losing the airway? I can see that but I'm offering an alternative. Not necessarily a better approach but just mentioning that it can be done this way and I personally would not have much concern doing it this way since I have done many. Still you must topicalization. But I am not aware of any of my partners having an issue with this. It works quite well.

Have you done it?

 

[Arch Guillotti]

Why not? They are breathing spontaneously. Are you afraid of losing the airway? I can see that but I'm offering an alternative. Not necessarily a better approach but just mentioning that it can be done this way and I personally would not have much concern doing it this way since I have done many. Still you must topicalization. But I am not aware of any of my partners having an issue with this. It works quite well.

Have you done it?

I have done plenty of LMA's for EBUS, never for mediastinoscopy (which is the original case presented).

 

[Noyac]

I have done plenty of LMA's for EBUS, never for mediastinoscopy (which is the original case presented).

Oops. I was thing this ended up as an EBUS for some reason.

Carry on!!!

 

[Planktonmd]

You are right. Instead you should just shove the bronchoscope in and make them cough like crazy while you attempt to examine the trachea.😉

No... You do a transtracheal injection then you can examine the trachea all you want.