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seinfeld

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ON call last night get the call I dream of, ruptured AAA coming to the OR. Run into Vascular surgeon, 60 something year old,review CT scan with him and it shows 11cm suprarenal AAA with rupture. Patient arrives in OR, quick hx reveals she doesnt see doctor regularly, she is barley responsive. Move to OR table, nurses prep belly, surgeon scrubbed and ready as I place left SC MAC cordis, CRNA puts in R radial aline and BP reads 45/20. Uncrossed PRBC flying in. Drapes up, small dose of versed, 100mg zemuron, Tube in easily, surgeon in belly immediately, BP drops to nothing, 50MCG epi, vasopressin chasers, Supraceliac clamp is on and bp up to 160 nicely, start NITRO drip and crank the gas. HCT 10 and pH 7.1 on first gas. VFIB then ensues x2 with ultimate successful cardioversions. I place TEE probe and see good function with no RWMA's valves all are good, no LV overdistention from high cross clamp. Float PA cath, Resuscitation in the usual manner for 3 hours, patient leaves OR with normal ABG no base excess, nl elctrolytes and HCT 30, INR 1.1. Post op requires diuresis for oxygenation and high filling pressures.

This is why is went into anesthesia. Love what you do and you wont work a day in your life!!!

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How much time between getting the call and getting the patient in the room? The things I fear about these cases are not having enough time from being told that the patient is coming to having them get through the OR doors and then simply running out of time before you can resuscitate.
 
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I've done about 10 of these cases. Only 2 left the hospital in a car. The other 8 left in body bags.
I'm glad you like these cases. I don't. Nothing intellectual about this type of case. Typically this type of patient is non compliant and rarely sees a physician.

You did a good job but I not sure society's resources should be spent this way
I'm sorry if it sounds harsh but That's how I feel

A mediocre surgeon makes leaving the operating without an acidosis or coagulopathy unlikely
 
I've done about 10 of these cases. Only 2 left the hospital in a car. The other 8 left in body bags.
I'm glad you like these cases. I don't. Nothing intellectual about this type of case. Typically this type of patient is non compliant and rarely sees a physician.

You did a good job but I not sure society's resources should be spent this way
I'm sorry if it sounds harsh but That's how I feel

A mediocre surgeon makes leaving the operating without an acidosis or coagulopathy unlikely

Despite you post being accurate sometimes saying nothing is the correct reply.

So much doom and gloom on this site and sermo (why i don't go on these sites as much as I used to ) I thought I would post an uplifting message to those who are still trying to find value in their daily vocations
 
Seinfeld,

Thanks for posting this! I'll be starting my pgy1 next year, and these fast paced cases where your skills and knowledge make a difference are the reason I look forward to a (hopefully) long career in gas!

Keep them up!
 
That woman just joined the 10% club. Good case. Had several of those in residency, no survivors.
 
Nothing intellectual about this type of case.

I remember another poster saying the same thing about a great case posted by an individual concerning new onset sepsis the the O.R. That is the most replied to thread in the private forum for those interested.

Seinfeld, in less chaotic situations do your surgeons request any pharmacological agents prior to clamping such as mannitol? Views?
 
Blade, I hear you to some extent, but there's also intrinsic, technical, value to the individual during a case like this.

I agree that often those big cases aren't full of finesse, exactly, but they're still big a.ss cases with a lot of techie stuff to use in aiding your management. That's also what I like about them.

Also, the way I've come to "justify" all the madness in terms of resources thrown at people like this is that the people doing them now have another notch under the belt and maybe that will be useful when taking care of someone like a relative.
The mind is a powerful thing.....lol
 
I've done about 10 of these cases. Only 2 left the hospital in a car. The other 8 left in body bags.
I'm glad you like these cases. I don't. Nothing intellectual about this type of case. Typically this type of patient is non compliant and rarely sees a physician.

You did a good job but I not sure society's resources should be spent this way
I'm sorry if it sounds harsh but That's how I feel

A mediocre surgeon makes leaving the operating without an acidosis or coagulopathy unlikely

As for the bolded ... I'll stop learning when I'm dead, man.

You've also got to realize that "rarely seeing a physician" is starkly different than noncompliance.
 
Seinfeld: kudos... Blade: thumbs down. It was a good case to share even if I doesn't give us something to mentally masturbate for six days and 200 posts. Some of us still like this job; some of us tolerate this job; some of us hate going to work every minute of every loathsome hour. Regardless, I applaud Seinfeld for the case discussion. I've always respected Blade for a whole host of reasons. Blade you rock... that much hasn't changed. But come on man, cut the guy some slack.
 
Despite you post being accurate sometimes saying nothing is the correct reply.

So much doom and gloom on this site and sermo (why i don't go on these sites as much as I used to ) I thought I would post an uplifting message to those who are still trying to find value in their daily vocations

BLADE, READ THE ABOVE ENHANCED S H IT FROM SEINFELD.

Your post reminds me of an attending I had in residency who would

OVERLOOK THE NINETY-NINE THINGS I DID RIGHT

and concentrate on the

ONE THING

I did wrong.

BAD POST MAN.

I'll give you a Mulligan on this one since you are in the Top Five Valuable Contributors here.
 
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I've done about 10 of these cases. Only 2 left the hospital in a car. The other 8 left in body bags.
I'm glad you like these cases. I don't. Nothing intellectual about this type of case. Typically this type of patient is non compliant and rarely sees a physician.

HUH?

DID YOU JUST SAY THAT?

"NOTHING INTELLECTUAL ABOUT THIS CASE?"


Yeah ok man.

A case almost

EXACTLY LIKE THIS

had a MAJOR impact on me.

Which I posted here long ago.

A BLEEDING TRIPLE A BROUGHT DIRECTLY TO THE OPERATING ROOM BY THE PARAMEDICS

Can one of you computer studs find that post?

BLADE, I STILL LOVE YOU MAN BUT THAT WAS AN

INAPPROPRIATELY PLACED

DEBBY DOWNER


post.
 
ON call last night get the call I dream of, ruptured AAA coming to the OR. Run into Vascular surgeon, 60 something year old,review CT scan with him and it shows 11cm suprarenal AAA with rupture. Patient arrives in OR, quick hx reveals she doesnt see doctor regularly, she is barley responsive. Move to OR table, nurses prep belly, surgeon scrubbed and ready as I place left SC MAC cordis, CRNA puts in R radial aline and BP reads 45/20. Uncrossed PRBC flying in. Drapes up, small dose of versed, 100mg zemuron, Tube in easily, surgeon in belly immediately, BP drops to nothing, 50MCG epi, vasopressin chasers, Supraceliac clamp is on and bp up to 160 nicely, start NITRO drip and crank the gas. HCT 10 and pH 7.1 on first gas. VFIB then ensues x2 with ultimate successful cardioversions. I place TEE probe and see good function with no RWMA's valves all are good, no LV overdistention from high cross clamp. Float PA cath, Resuscitation in the usual manner for 3 hours, patient leaves OR with normal ABG no base excess, nl elctrolytes and HCT 30, INR 1.1. Post op requires diuresis for oxygenation and high filling pressures.

This is why is went into anesthesia. Love what you do and you wont work a day in your life!!!

I've only done a handful of ruptured AAAs in residency. None survived to discharged and one died in the OR. Impressive that your CRNA was able to get an A-line with that low of a pressure. Even more impressive that you got the patient out of the OR with normal looking labs.

While I wouldn't call get a case like that the call I dream of, I do agree with you about the importance of loving what you do.

Congrats on getting her out of the OR and thanks for sharing.
 
I remember another poster saying the same thing about a great case posted by an individual concerning new onset sepsis the the O.R. That is the most replied to thread in the private forum for those interested.

Seinfeld, in less chaotic situations do your surgeons request any pharmacological agents prior to clamping such as mannitol? Views?

I gave mannitol and some lasix (once i knew her pressure responded to cross clamp). Mannitol a free radical scavenger and also helps "flush" those renal tubules from the junk of cellular death, there was a NEJM review article a few years ago on its use. Plus in this case the lady was only 63" and 61kg i knew that volume overload from products would eventually catch up with me when the bleeding stopped.

We have an older guy who wants dopamine 2-3 m/k/m for elective open repairs. I dont mind as long as no hx of AFIB/SVTs. I asked him why he liked it and he smartly replied that it would not prevent renal failure but he liked to see the patients urine output stay up and was using it as a diuretic more than anything. He is the only one i use it for and will always shut it off if i get any tachycardia.
 
ON call last night get the call I dream of, ruptured AAA coming to the OR. Run into Vascular surgeon, 60 something year old,review CT scan with him and it shows 11cm suprarenal AAA with rupture. Patient arrives in OR, quick hx reveals she doesnt see doctor regularly, she is barley responsive. Move to OR table, nurses prep belly, surgeon scrubbed and ready as I place left SC MAC cordis, CRNA puts in R radial aline and BP reads 45/20. Uncrossed PRBC flying in. Drapes up, small dose of versed, 100mg zemuron, Tube in easily, surgeon in belly immediately, BP drops to nothing, 50MCG epi, vasopressin chasers, Supraceliac clamp is on and bp up to 160 nicely, start NITRO drip and crank the gas. HCT 10 and pH 7.1 on first gas. VFIB then ensues x2 with ultimate successful cardioversions. I place TEE probe and see good function with no RWMA's valves all are good, no LV overdistention from high cross clamp. Float PA cath, Resuscitation in the usual manner for 3 hours, patient leaves OR with normal ABG no base excess, nl elctrolytes and HCT 30, INR 1.1. Post op requires diuresis for oxygenation and high filling pressures.

This is why is went into anesthesia. Love what you do and you wont work a day in your life!!!

One of the many reasons why I plan to go into cardiac (hopefully). Stressful, intense cases on super sick pts like this, use of multiple vasoactive infusions and intraop TEE peaks my interest. Kudos on pulling the pt through and thanks for sharing.
 
So much doom and gloom on this site and sermo (why i don't go on these sites as much as I used to ) I thought I would post an uplifting message to those who are still trying to find value in their daily vocations

I'll chime in too and say it's appreciated. Part of what got me through undergrad was working EMS and in the ED seeing patients. We don't get much patient contact during our pre-clinical years, so threads like these are a nice little reminder of what all this painful Step I studying is building towards.

A BLEEDING TRIPLE A BROUGHT DIRECTLY TO THE OPERATING ROOM BY THE PARAMEDICS

This one? http://forums.studentdoctor.net/showthread.php?t=478127&highlight=paramedics
 
I'll chime in too and say it's appreciated. Part of what got me through undergrad was working EMS and in the ED seeing patients. We don't get much patient contact during our pre-clinical years, so threads like these are a nice little reminder of what all this painful Step I studying is building towards.



This one? http://forums.studentdoctor.net/showthread.php?t=478127&highlight=paramedics

DRUGGERNAUT,

YES!

You found a post I was in on from SIX YEARS AGO which emulates the OP's experiences.

Thanks man.
 
PLUS,

This thread Drug drug up has UT SOUTHWESTERN in it, who most of you know isn't with us anymore.

Thanx again Drug
 
Well done.

Had similar case a few weeks ago. 50ish man with ruptured infrarenal AAA, diagnosed at another hospital and flown to ours. Surgeon sends patient directly to ct for delineation of anatomy. Then brought to OR. Hypotensive on arrival to the or(50s/30s), tachycardic, obtunded, sweating. Bolused dexmedetomidine, tossed in a cordis in the right ij, started dumping in fluids and blood through Belmont. placed radial a-line. Surgeon used endovascular approach, never opens the belly. We get through the case using just dexmedetomidine sedation. Patient discharged home within a week. Surgeon is awesome.

Had he opened the belly, the guy would have died.
 
Wth BP 50/30 and you bolus dexmedetomidine? Glad it worked but that Seems like a great time for scopolamine, ketamine, etomidate, or nothing at all. Same for the OPs versed in a pt in shock.
 
Wth BP 50/30 you bolus dexmedetomidine? Glad it worked but that Seems like a great time for scopolamine, ketamine, etomidate, or nothing at all. Same for the OPs versed in a pt in shock.

Yea, I knew the dex in a patient with hypovolemic shock would upset like 99.9% of people on here.

Its not what I would have done, but my attending has had good experiences with it. In this case we couldnt have hoped for a better outcome.

We literally never use scopolamine at our program. I don't even know how we would get it, we don't stock it in our pyxis machines.
 
Great case seinfeld.

Our shop just had a run of these- 4 in one week. Bizarre. 2 made it. 2 didn't.

You give me a MAC catheter and a Belmont for these and I'm a happy man.

I love the f'ing Belmont.
 
Great case seinfeld.

Our shop just had a run of these- 4 in one week. Bizarre. 2 made it. 2 didn't.

You give me a MAC catheter and a Belmont for these and I'm a happy man.

I love the f'ing Belmont.

Belmonts are great. The only thing better than a Belmont is a Belmont with dedicated staff feeding it.

Our setup for trauma out here in the dirt is a Belmont in each bay with two nurses running it. They follow us to the OR. Transfusing is as easy as "give two more units of RBCs and two more FFP" and it just happens. One of the nurses is pulled from the ICU when the trauma page goes out, and at the end of the case the same nurse rotates back into the ICU and continues care. It's nice to have one nurse from the instant the patient came to the ER through the OR to the ICU. It's a glorious well-oiled machine.
 
Its been a while so....how much ketamine would you "induce" this pt with? 0.5cc/kg? What about for awakes?

We dont have MACs where I am but they sound kickass!
 
Dang. That was intense. Sounds amazing, glad it had a good (short term) outcome! Hope it continues. I'm gonna send this to a couple of my buddies who have recently been thinking about anesthesia. :cool:

Seinfeld: I had thought you were a CCM guy, do you also do cardiac? Did you do double fellowships? Just curious. Thanks for the post, very enjoyable reading for an M3 aspiring to be an anesthesiologist!
 
There is something wrong with you awesome about you.

I think this is what you meant.

I am still a student and recognize that I don't know cephalad from caudad, but my time with trauma, and various ICUs confirmed for me that I like 'em sick. Cases like the one Seinfeld just posted are why CCM and Cardiac are appealing to me.


Just my (self) over-valued $0.02.
 
Ugh. My place is a community hospital, not a trauma center, and the level 1 infusor is out of service. When we get a ruptured AAA, the ED can't be bothered to do any lines or send a nurse with the patient mashing blood in. So we get them dry and scary. Have to set up our own IV setups and transducers quick, as there is no after hours tech. Once in while there is an extra nurse to squeeze blood while you put in lines, but usually we have them running to get blood and surgical equipment. I think I'm 3 for 4, with the 4th already pretty much dead on arrival with BP 40s on epi drip.
 
:soexcited:
There is something wrong with you.

LOL, Despite my interest in ICU/cardiac/vascular and the "big" elective case when I am on call I always tend to have those vanilla nights. A C-section for failure to progress, an appy etc. I was happy to finally have a real life and death case when on -call. I remember in residency one of my colleagues who wanted to do bread and butter outpt stuff got a bunch of liver transplants, ruptured AAA, emergency VADs etc. but I never got anything remotely interesting.
 
Seinfeld: I had thought you were a CCM guy, do you also do cardiac? Did you do double fellowships? Just curious. Thanks for the post, very enjoyable reading for an M3 aspiring to be an anesthesiologist!

I did a CCM fellowship and spent time learning TEE during residency and fellowship. I graduated before the new rules about having to do a fellowship to become certified in TEE came out. At our hospital certification is not a requirement to read TEE. Passing the exam, CME, and being signed off by the head of cardiac anesthesia is required.
 
ON call last night get the call I dream of, ruptured AAA coming to the OR. Run into Vascular surgeon, 60 something year old,review CT scan with him and it shows 11cm suprarenal AAA with rupture. Patient arrives in OR, quick hx reveals she doesnt see doctor regularly, she is barley responsive. Move to OR table, nurses prep belly, surgeon scrubbed and ready as I place left SC MAC cordis, CRNA puts in R radial aline and BP reads 45/20. Uncrossed PRBC flying in. Drapes up, small dose of versed, 100mg zemuron, Tube in easily, surgeon in belly immediately, BP drops to nothing, 50MCG epi, vasopressin chasers, Supraceliac clamp is on and bp up to 160 nicely, start NITRO drip and crank the gas. HCT 10 and pH 7.1 on first gas. VFIB then ensues x2 with ultimate successful cardioversions. I place TEE probe and see good function with no RWMA's valves all are good, no LV overdistention from high cross clamp. Float PA cath, Resuscitation in the usual manner for 3 hours, patient leaves OR with normal ABG no base excess, nl elctrolytes and HCT 30, INR 1.1. Post op requires diuresis for oxygenation and high filling pressures.

This is why is went into anesthesia. Love what you do and you wont work a day in your life!!!

Nice job! I'm usually arguing with the surgeon to hold the incision until the cordis is in because I need access before the tamponade is released when the belly is opened.
 
Awesome case man. Cases like these make me wish I had gone gas/CC instead of IM/CC. There is nothing like the adrenaline rush of having a pt standing on Gods front porch and pulling them back from the light. I'm sure it gets a little less interesting after 25 years and a zillion of these cases but until that happens I am going to keep loving them. Unfortunately I don't get these pts till they get to the MICU post op so I get to miss out on that fun. I'm in a community shop so I hate getting these cases here. Nearly all of them die, (6/7) that i have been a part of, and they wipe out our blood bank.
 
Its been a while so....how much ketamine would you "induce" this pt with? 0.5cc/kg? What about for awakes?

We dont have MACs where I am but they sound kickass!

MAC is my absolute favorite line!!!! My new place doesn't stock them but I'm working on it. It's 9.5 Fr line, 2 ports (9 Fr and 12 ga), plus introducer for PAC or SLIC.
 
There is something wrong with you.

These cases are no-lose propositions.

If the patient dies, well, he had a ruptured AAA. We did what we could. The patient is the one with the disease.

If the patient lives, it's a great save. Heroic work. High fives all around.
 
Few questions from a CA-1 if someone cares to respond....

1. An above post mentioned inducing with ketamine. Wouldn't that not be wise due to already existing depletion of catecholamines?

2. What is the need to float the PA cath if you already have a TEE probe. Not sure if you have FloTrak that hooks up to the A-line but if you did would that alleviate the need for the PA cath.

3. Did you call for pacer pads for defib to be placed on the patient prior to the episodes in anticipation of a code or did you call for them as they happened.

Just a junior resident trying to learn. Thanks!
 
Few questions from a CA-1 if someone cares to respond....

1. An above post mentioned inducing with ketamine. Wouldn't that not be wise due to already existing depletion of catecholamines?

2. What is the need to float the PA cath if you already have a TEE probe. Not sure if you have FloTrak that hooks up to the A-line but if you did would that alleviate the need for the PA cath.

3. Did you call for pacer pads for defib to be placed on the patient prior to the episodes in anticipation of a code or did you call for them as they happened.

Just a junior resident trying to learn. Thanks!
 
Few questions from a CA-1 if someone cares to respond....

1. An above post mentioned inducing with ketamine. Wouldn't that not be wise due to already existing depletion of catecholamines?

2. What is the need to float the PA cath if you already have a TEE probe. Not sure if you have FloTrak that hooks up to the A-line but if you did would that alleviate the need for the PA cath.

3. Did you call for pacer pads for defib to be placed on the patient prior to the episodes in anticipation of a code or did you call for them as they happened.

Just a junior resident trying to learn. Thanks!

In regard to question one I believe there is a question from the Hall book that would support your line of reasoning.
 
Few questions from a CA-1 if someone cares to respond....

1. An above post mentioned inducing with ketamine. Wouldn't that not be wise due to already existing depletion of catecholamines?

2. What is the need to float the PA cath if you already have a TEE probe. Not sure if you have FloTrak that hooks up to the A-line but if you did would that alleviate the need for the PA cath.

3. Did you call for pacer pads for defib to be placed on the patient prior to the episodes in anticipation of a code or did you call for them as they happened.

Just a junior resident trying to learn. Thanks!

PA cath 2 things. 1. Despite TEE being a great tool intraop you can't always leave it on , it requires your eyes and 2 hands therefore trending and noticing acute changes is more difficult. 2. I like to be able to hand off to the ICU information that they can also use i.e. When the PAD was 22 the LV looked full and BP/CI/SVO2 were optimized.

I learned quick in emergency/big surgeries have the nurses/anesthesia techs place the pads before prepping
 
Few questions from a CA-1 if someone cares to respond....

1. An above post mentioned inducing with ketamine. Wouldn't that not be wise due to already existing depletion of catecholamines?

2. What is the need to float the PA cath if you already have a TEE probe. Not sure if you have FloTrak that hooks up to the A-line but if you did would that alleviate the need for the PA cath.

3. Did you call for pacer pads for defib to be placed on the patient prior to the episodes in anticipation of a code or did you call for them as they happened.

Just a junior resident trying to learn. Thanks!

honestly with pressures of 40/20 you can induce with anything, it doesnt matter. ketamine and etomidate may depress the myocardium further in high catecholamine states, so just dont overdo it. id probably give a little lido some versed and RSI paralytic of choice, but wouldnt turn down ketamine if it were handed to me,

PAC allows for continuous monitoring of filling pressures, most helpful to look at trends. i also like MVO2. TEE is really a snapshot of wall motion and ventricular function/filling. ive made this same argument before and ive come to learn that they really do have different value.

i dont think that i would have pads open and on the patient before the arrhythmia. sometimes they come up from the ED like that
 
We have an older guy who wants dopamine 2-3 m/k/m for elective open repairs. I dont mind as long as no hx of AFIB/SVTs. I asked him why he liked it and he smartly replied that it would not prevent renal failure but he liked to see the patients urine output stay up and was using it as a diuretic more than anything. He is the only one i use it for and will always shut it off if i get any tachycardia.

Dopamine is a kick-as s diuretic.
 
I've done about 10 of these cases. Only 2 left the hospital in a car. The other 8 left in body bags.

Blade's dim view of this operation as high-risk, high-mortality is correct...but the fatalism?

This kind of high-risk patient is exactly the kind of scenario where you, the anesthesiologist, can make some high-benefit interventions.

The mortality data are scary. But those outcome data are based on how the patient leaves the OR, not how they enter it.

In between, you help decide their outcome, not chance.
 
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