Happy Holidays - my gift from ENT

[Noyac]

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this was my case before leaving town to spend the holidays with family.

Problem List:
1. Diffuse Large Tumor of the thyroid - suspected metastatic lesion to spleen
2. Airway obstruction secondary to large tumor mass in neck (pt lost his voice and had difficulty breathing supine the week prior and it improved with a steroid dose pack.)
3. HepaticCirrhosis with paraesophageal varices and portal vein thrombosis - suspect secondary to NASH. Studies do not support hemachromatosis. No history of alcohol abuse.
4. Impaired hepatic synthetic function with evidence of coagulopathy and hypoalbumenia
5. Chronic Thrombocytopenia secondary to chronic liver disease and hypersplenism
6. Hypothyroidism - on Thyroid replacement medication
7. HTN treated with Nadolol
8. Agitated delirium and confusion post anesthesia
9. Anemia secondary to chronic disease - malignancy, cirrhosis
10. Elevated ammonia - no clinical evidence of hepatic encephalopathy
11. Obesity-BMI 38


CT NECK - 12/14/18: IMPRESSION:
1. Infiltrating mass centered in or adjacent to the right thyroid gland and in the prevertebral soft tissues posterior to the larynx. Tumor infiltration of the vocal cord on the right, the cricoid cartilage and arytenoid cartilage. Craniocaudal extent is from the C-3 vertebral body level to the upper mediastinum below the level the clavicular heads.
2. Atherosclerotic disease within carotid bulbs.

Plan:
-ENT wants to go into the OR and get a good biopsy specimen for pathology because the fine needle aspirations all returned with necrotic tissue unable to differnciate. They need a good sample to determine whether to do radiation, chemo or both.




Go!!!

 

[deleted171991]

MAC with a lot of local. Ketamine boluses plus remifentanil infusion (or similar, pick your poison), maintaining spontaneous ventilation, with the patient in reverse Trendelenburg. ENT needs to dissect to the tumor FROM THE OUTSIDE (no airway manipulation, not with a pole).

Preinduction femoral cannulations, ready to go on CP bypass, with cardiac surgeon and perfusionist in the room.

Preop platelet/PCC transfusion as needed.

Properly informed consent. Patient and family need to be told that this won't be a walk in the park.

 

[Noyac]

We don’t have bypass capabilities FYI.

 

[deleted171991]

We don’t have bypass capabilities FYI.

I assumed so. 😀

Tough luck for the patient. Short of transferring him to a place which does (patient choice), it wouldn't alter my plan.

One thing is clear: this case needs an excellent and fast surgeon, and an anesthesiologist who's a master of MAC.

 

[Noyac]

One thing is clear: this case needs an excellent and fast surgeon, and an anesthesiologist who's a master of MAC.

Let me just start with this. I gave this pt 1mg of versed to relieve his severe anxiety of what he was about to undergo. He went apnic. Never was able to start the Remi. It got a bit sketchy at this point.

 

[coffeebythelake]

Def high risk. Lots of local. Minimal sedation.

 

[vector2]

Let me just start with this. I gave this pt 1mg of versed to relieve his severe anxiety of what he was about to undergo. He went apnic. Never was able to start the Remi. It got a bit sketchy at this point.

Give him the romazicon and put the mask on while ENT preps the neck and starts localizing. With that CT and being symptomatic that guy needed an awake trach last week.

 

[narcusprince]

Afoi remi off/on extubate with a smooth remi wakeup. Remimazolam for anxiety.

 

[CodeBlu]

Local. Local. Local.
Get your tissue. But, then awake trach. Spontaneous ventilation at all times. No drugs other than local. Nope nope nope.

Can't AFOI that... it's pinhole!

 

[pgg]

Afoi remi off/on extubate with a smooth remi wakeup. Remimazolam for anxiety.

I would not attempt an AFOI. That CT suggests to me that a scope might totally obstruct him all by itself. Even with care and skill, some of these angry friable airway tumors will bleed and swell at the slightest touch, and then you're boned.

If this guy gets a plastic airway it's going to have to go in surgically through the neck.

 

[VisionaryTics]

I would not attempt an AFOI. That CT suggests to me that a scope might totally obstruct him all by itself. Even with care and skill, some of these angry friable airway tumors will bleed and swell at the slightest touch, and then you're boned.

If this guy gets a plastic airway it's going to have to go in surgically through the neck.

Trachs in these invasive thyroid cancers (anaplastic, insular cell, etc) are disasters. I've seen 2L blood loss during isthmusectomy to even expose the trachea.

Woof, would love to hear the outcome of this.

 

[betamale]

this was my case before leaving town to spend the holidays with family.

Problem List:
1. Diffuse Large Tumor of the thyroid - suspected metastatic lesion to spleen
2. Airway obstruction secondary to large tumor mass in neck (pt lost his voice and had difficulty breathing supine the week prior and it improved with a steroid dose pack.)
3. HepaticCirrhosis with paraesophageal varices and portal vein thrombosis - suspect secondary to NASH. Studies do not support hemachromatosis. No history of alcohol abuse.
4. Impaired hepatic synthetic function with evidence of coagulopathy and hypoalbumenia
5. Chronic Thrombocytopenia secondary to chronic liver disease and hypersplenism
6. Hypothyroidism - on Thyroid replacement medication
7. HTN treated with Nadolol
8. Agitated delirium and confusion post anesthesia
9. Anemia secondary to chronic disease - malignancy, cirrhosis
10. Elevated ammonia - no clinical evidence of hepatic encephalopathy
11. Obesity-BMI 38


CT NECK - 12/14/18: IMPRESSION:
1. Infiltrating mass centered in or adjacent to the right thyroid gland and in the prevertebral soft tissues posterior to the larynx. Tumor infiltration of the vocal cord on the right, the cricoid cartilage and arytenoid cartilage. Craniocaudal extent is from the C-3 vertebral body level to the upper mediastinum below the level the clavicular heads.
2. Atherosclerotic disease within carotid bulbs.

Plan:
-ENT wants to go into the OR and get a good biopsy specimen for pathology because the fine needle aspirations all returned with necrotic tissue unable to differnciate. They need a good sample to determine whether to do radiation, chemo or both.




Go!!!

Cool then discharge home afterwards with ER precautions to a free standing ED nearby if bleeding or shortness of breath occurs...

Trach first...post-op hematoma and swelling is gonna be a bitch... This showed up in my free standing ED btw...not cool

 

[Psai]

DNR DNI

Don't hasten death with heroics

 

[sevoflurane]

I already know how this case is gonna go as Noy and I discusses this last week.

My first thought when I saw the CT was awake trach.

 

[sevoflurane]

Gnarly AW based on CT.

 

[deleted162650]

Awake casket fitting.

 

[okayplayer]

Don’t have much to add beyond what has been contributed, but holy **** that is an impressive CT. No wonder he has been short of breath and having vocal symptoms.

It always astonishes me when patients let things go to this point.

 

[pgg]

Trachs in these invasive thyroid cancers (anaplastic, insular cell, etc) are disasters. I've seen 2L blood loss during isthmusectomy to even expose the trachea.

Woof, would love to hear the outcome of this.

Yeah they can be a mess. But still better than the alternative of a lost airway with no surgeon in sight.

Anyway. This guy can barely breathe right now, before we even do anything. He has a stronger indication for a trach than the biopsy. You could do a graceful beautiful anesthetic for this biopsy, and then he drops dead tomorrow or next week when his last mm of patent airway gets obstructed.

He needs a trach, not someone poking the bear and stirring up trouble.

 

[Mman]

while this patient needs a trach, that's the kind of CT that makes me not sure even a great ENT can even do one in an awake patient. I've seen sort of similar looking neck CTs and had the ENT tell me after we got an AFOI that they weren't even sure they'd be able to trach them without resecting first. I mean the patient can't even lay flat in the first place. How the heck do you position them? I'd almost wonder if I need to go borrow the Heliox from our PICU for this guy to be able to breathe.

 

[periopdoc]

Even without the biopsy, the dude is going to die without a trach, but it’s going to be a challenge to trach him.

Take your time, lots of local, have your narcan and romazicon drawn up in advance and don’t give him anything except a benzo, some opiate, and glyco.

Do you have access to heliox?

Edited to add that I should have read Mman’s post before responding. I see he brought up heliox too.

 

[anbuitachi]

If ent can't do it under local. Then Afoi sitting up w ent at bedside.

Why do you think patient went apneic after 1 of midaZ?

 

[MirrorTodd]

Do you need a resident to do a case write up? Lol

 

[drmwvr]

If ent can't do it under local. Then Afoi sitting up w ent at bedside.

Why do you think patient went apneic after 1 of midaZ?

3 digit PaCO2?

 

[narcusprince]

I would not attempt an AFOI. That CT suggests to me that a scope might totally obstruct him all by itself. Even with care and skill, some of these angry friable airway tumors will bleed and swell at the slightest touch, and then you're boned.

If this guy gets a plastic airway it's going to have to go in surgically through the neck.

This is a bad situation. I would intubate with a MLT tube and extubate wide awake. I had a similar case. Their approach was asleep glidescope with a fiberoptic. If their is any extension of the tumor into the trachea or tracheal compression afoi. Maintain airway reflexes. Whats worse you biopsy and then the tumor bleeds and swells now you have to intubate a swollen bloody airway. Versus securing the airway and waking with reflexes intact. Also after the afoi im taking a look with the glidescope to help my partners out to see what view I could obtain. Either way ent is at the bedside and airway is painted for an emergency trach. This case needs to be done at a hospital that can get this patient on bypass. Also have a long conversation with family that their are high odds the patient will not make it through the procedure.

 

[deleted162650]

Why do you think patient went apneic after 1 of midaZ?

The liver Dz probably had something to do with it.

 

[anbuitachi]

3 digit PaCO2?

apnea would cause 2 digit paco2 ..

 

[propadope]

Even without the biopsy, the dude is going to die without a trach, but it’s going to be a challenge to trach him.

Take your time, lots of local, have your narcan and romazicon drawn up in advance and don’t give him anything except a benzo, some opiate, and glyco.

Do you have access to heliox?

Edited to add that I should have read Mman’s post before responding. I see he brought up heliox too.

But he didn’t tolerate 1mg versed...

 

[propadope]

If ent can't do it under local. Then Afoi sitting up w ent at bedside.

Why do you think patient went apneic after 1 of midaZ?

I’m guessing OSA along with the obstructing tumour

 

[Psai]

MAC with a lot of local. Ketamine boluses plus remifentanil infusion (or similar, pick your poison), maintaining spontaneous ventilation, with the patient in reverse Trendelenburg. ENT needs to dissect to the tumor FROM THE OUTSIDE (no airway manipulation, not with a pole).

Preinduction femoral cannulations, ready to go on CP bypass, with cardiac surgeon and perfusionist in the room.

Preop platelet/PCC transfusion as needed.

Properly informed consent. Patient and family need to be told that this won't be a walk in the park.

You would really put this patient on bypass? I wouldn't even offer it. What are you trying to do, drown the guy with blood in the airway after heparinization?

 

[pgg]

This is a bad situation. I would intubate with a MLT tube and extubate wide awake.

I'm just not seeing it. 🙂

May the force be with anyone who tries to intubate that.

 

[deleted171991]

Let me just start with this. I gave this pt 1mg of versed to relieve his severe anxiety of what he was about to undergo. He went apnic. Never was able to start the Remi. It got a bit sketchy at this point.

Flumazenil? 🙂

 

[deleted171991]

You would really put this patient on bypass? I wouldn't even offer it. What are you trying to do, drown the guy with blood in the airway after heparinization?

That's the backup plan, dude, for when you lose the airway. You know, it could happen to those less talented (or unlucky!) of us. One can even drown the patient in his own blood afterwards, with no effect on gas exchange. 😉

 

[deleted171991]

To those singing the merits of an awake trach, it usually takes about 30-45 minutes to dissect down to the trachea with such a monster of a tumor. Also it can bleed like a pig.

 

[deleted171991]

I’m guessing OSA along with the obstructing tumour

Or congested airway due to venous compression.

 

[Mman]

This is a bad situation. I would intubate with a MLT tube and extubate wide awake.

You would extubate them afterwards?????!?!?!?!??!?!?!?

If by some miracle I decided to do an AFOI on this patient and actually got the tube in, that tube is only being removed for the trach to be passed. Once they are asleep with a tube in the surgeon can take all damn day to resect whatever they want (or nothing at all) to get down to their airway and get a trach.

 

[Mman]

Edited to add that I should have read Mman’s post before responding. I see he brought up heliox too.

I've only seen Heliox used (other than in diving) in the PICU in kids in status asthmaticus on the vent right before we start adding sevoflurane to the mix. Have never seen it used in an awake patient but I can't imagine it would hurt given their tenuous status.

 

[Mr.S]

oxygen

awake fiberoptic
+/- trach
let them do the biopsyy
agree with remi
nothing long acting
90% chance of extubating if nothing long acting given
5% chance if ANY fentanyl on board

Key question: SHould you trach him intra op after induction?
Should he be discharged immediately afte operation or observed overnight in the ICU

Sedation/MAC is the wrong anesthetic. The airway will be lost almost assuredly.

 

[Psai]

That's the backup plan, dude, for when you lose the airway. You know, it could happen to those less talented (or unlucky!) of us. One can even drown the patient in his own blood afterwards, with no effect on gas exchange. 😉

It'll probably happen before they get the patient fully on bypass with his crap liver, coagulopathy, thrombocytopenia, large tumor. Presumably you're trying to get them off bypass eventually without a huge clot taking up the entire tracheobronchial tree.

When you guys get the fiberoptic out it will probably be covered in secretions and or blood immediately and you won't see ****.

 

[nimbus]

How wide is that airway...3-4mm? What tube would you use? I like the femoral cannulation idea.

 

[Mman]

90% chance of extubating if nothing long acting given
5% chance if ANY fentanyl on board

I don't get the idea of extubating. The presence of an endotracheal tube for any time is going to cause swelling in this airway and it's not like there was any extra room in there to start with. I mean are we going to pretend he'll have a cuff leak at the end of the case? The presence of any sort of drug you want to provide general anesthesia with is going to blunt his wakefulness and airway reflexes. I mean awake extubation? Sure, we say that, but they are never as awake during extubation as they were in preop holding where he was barely hanging on. Plus just wait til he coughs on that tube once or twice and the blood and secretions are everywhere in his oropharynx.

The old rule of thumb for everyone else in the OR (circulator, tech, surgeon, etc) is don't pull out my ET tube if you can't put it back in. I'm pretty sure I'd never it get it back in this patient postop so I'm going to follow that advice and not pull it out.

 

[deleted162650]

How wide is that airway...3-4mm? What tube would you use?

2.5

 

[IMGASMD]

Let me just start with this. I gave this pt 1mg of versed to relieve his severe anxiety of what he was about to undergo. He went apnic. Never was able to start the Remi. It got a bit sketchy at this point.

So far I’m only at this post, #6? I am ****ting my pants already...... can’t wait for what’s going to happen next.

 

[Mr.S]

I don't get the idea of extubating. The presence of any sort of drug you want to provide general anesthesia with is going to blunt his wakefulness and airway reflexes. I mean awake extubation? Sure, we say that, but they are never as awake during extubation as they were in preop holding where he was barely hanging on. Plus just wait til he coughs on that tube once or twice and the blood and secretions are everywhere in his oropharynx.

The old rule of thumb for everyone else in the OR (circulator, tech, surgeon, etc) is don't pull out my ET tube if you can't put it back in. I'm pretty sure I'd never it get it back in this patient postop so I'm going to follow that advice and not pull it out.

Leaving him intubated is not the wrong thing to do.. but it begs the question. Why? and for how long? youre going to have to extubate him at some point? in two hour? four hours? overnight? When? I take these things out after the case. NO FENTANYL.. MINIMAL VERSED and if you get the volatile agent off at end of case they will be wide awake. THe remi will help you accomplish that. The question remains will you ask the surgeon to trach him .. If he is trached then everything else is simple.

 

[Consigliere]

I would REFUSE to be a party to this nonsense.

 

[IlDestriero]

Palliative care consult and call for an earlier flight.

 

[okayplayer]

I was waiting for the dude who wanted a stress test on the other thread to come through...

 

[Noyac]

Great replies by everyone. I’ll admit that I got caught a bit off guard by this case because the ENT surgeon didn’t call me until the morning of. She said AFOI was probably indictated (no Shiite Sherlock). But she was just being polite as to not step on my toes and I appreciated it. Then I looked at the CT about an hour before the case.

So, I said his symptoms improved somewhat after a week of steroids. Does this change anyone’s plans or make you feel better about things?

 

[Mr.S]

I would REFUSE to be a party to this nonsense.

I refuse your honor.

 

[Mr.S]

Great replies by everyone. I’ll admit that I got caught a bit off guard by this case because the ENT surgeon didn’t call me until the morning of. She said AFOI was probably indictated (no Shiite Sherlock). But she was just being polite as to not step on my toes and I appreciated it. Then I looked at the CT about an hour before the case.

So, I said his symptoms improved somewhat after a week of steroids. Does this change anyone’s plans or make you feel better about things?

if they are moving air and not stridorous. youll be fine. with awake fiberoptic and extubation provided you dont od him with sublimaze

you perhaps can do a racemic epi breathing treatment prophylactically make him feel better.
in the pacu as well

 

[Noyac]

The old rule of thumb for everyone else in the OR (circulator, tech, surgeon, etc) is don't pull out my ET tube if you can't put it back in. I'm pretty sure I'd never it get it back in this patient postop so I'm going to follow that advice and not pull it out.

This is a bit tongue in cheek to many people here but it is an extremely important statement that Mman is making. Don’t think that he/she isn’t completely serious. My comment to everyone in the OR when they want to move the Pt or transfer them somehow is, “whom ever pulls the tube out had better be able to put it back in.” And I’m damn serious about that too. Whenever I say this everyone seems to step away from the Pt and wait until I am ready. It gives them an idea of what we do and how important it is.