How would you approach this case?

[thetoddJR]

Love seeing the discussions you geniuses have about cases. So here is one I did a few weeks back.
55y 152kg M scheduled for Maxillectomy, Parotidectomy, neck dissection, and radial arm free flap.
PMH: sub orbital SCC, IDDM (A1c 9.9), NAFLD s/p OLT about 7 years ago, moderate cervical stenosis on MRI, OSA (not on CPAP), HTN on beta blocker, HLD. No documented CAD, COPD, or CVA history.
No known airway involvement by tumor, but physical exam shows Mallampati 4
PSH:OLT, Carpal tunnel, MOHS
AH: No known Anesthetic complications. No airway history on file.
EKG shows SR without any concern for past ischemic changes

how would you approach this case? Did it recently and wondering what I could have done differently (all went well...im a CA1 so looking to see what else is out there)

---

Members don't see this ad.

 

[dp101]

interacting case, especially for a new ca1. I probably would placed a pre induction arterial like in the non operative arm. Explained to the patient the risk god airway poses both from being morbidly obese and having the mass. Done an awake nasal fiber optic. Nebulized lidocaine, nasal trumpets with lidocaine jelly , precedex. Take your time, don’t rush, as pt will likely require post op mech ventilation.

 

[deleted697535]

Well you really need to review the imaging and where the lesion is. Suborbital really shouldnt be in the airway at all but who knows.
Id have a discussion with ENT about trach'ing him

Id 70% do afoi but really these huge guys arent hard to intubate with a glidescope so if the imaging is favorable with good mouth opening a titanium blade glidescope can be just as good. BVMs not hard either necessarily. Just position well, oral airway. start phenyl running in line with an art line of course. Dont flood with fluids

99% going to ICU intubated post op given its going to be an all day case

Stress dose steroids and get some form of gastric tube in to give him his antirejection meds
Treat his sugars intra-op

 

[surgndoc]

Awake nasal foi, or asleep nasal FOI if you think you’d be able to ventilate the patient.

Aline, couple IVs, skimpy on the pressors and do an abg every few hours. Kick your feet up and read a book for the next 12 hours. They’ll probably do a Trach or pt will go to icu intubated.

At my old academic place these were the cherry picked cases by the laziest ppl because there’s was basically nothing to do after getting it started.

 

[dchz]

prop sux tube.

damn that's a lot of propofol.

 

[anbuitachi]

seems like a common flap case, with the only special thing being his weight.. usually these cancer patients are skinnier

but like others said, A line, 2 IV

Surprised by the # of ppl saying awake fiberoptic intubation.
This guys tumor is sub orbital, and theres no involvement with the airway.
What is his BMI? could be 152kg but 6ft +

Do prop sux tube. then A line, another IV.
check ABG every 2 hours to monitor the glucose.

Dont see why they would need to trach this patient.

 

[thetoddJR]

seems like a common flap case, with the only special thing being his weight.. usually these cancer patients are skinnier

but like others said, A line, 2 IV

Surprised by the # of ppl saying awake fiberoptic intubation.
This guys tumor is sub orbital, and theres no involvement with the airway.
What is his BMI? could be 152kg but 6ft +

Do prop sux tube. then A line, another IV.
check ABG every 2 hours to monitor the glucose.

Dont see why they would need to trach this patient.

BMI 47. We did awake because of weight, cervical stenosis (ROM was not great but not terrible), Mallampati 4. Anticipated Difficult ventilation and intubation. Also, COVID has a limit on glide scopes

 

[woopedazz]

I'd pop in a subclavian post-induction. They're going to ICU... why wouldn't you?

 

[chocomorsel]

Love seeing the discussions you geniuses have about cases. So here is one I did a few weeks back.
55y 152kg M scheduled for Maxillectomy, Parotidectomy, neck dissection, and radial arm free flap.
PMH: sub orbital SCC, IDDM (A1c 9.9), NAFLD s/p OLT about 7 years ago, moderate cervical stenosis on MRI, OSA (not on CPAP), HTN on beta blocker, HLD. No documented CAD, COPD, or CVA history.
No known airway involvement by tumor, but physical exam shows Mallampati 4
PSH:OLT, Carpal tunnel, MOHS
AH: No known Anesthetic complications. No airway history on file.
EKG shows SR without any concern for past ischemic changes

how would you approach this case? Did it recently and wondering what I could have done differently (all went well...im a CA1 so looking to see what else is out there)

I am sorry. This is a total waste of a liver which I hear are in short supply.

 

[gasman654]

With a mallampati 4, morbid obesity, uncontrolled OSA, and assuming limited cervical ROM on exam from his stenosis?, id say an awake FOI w some precedex, great topicalization and the head of the bed elevated would be my choice

This guy is probably hard to mask and you do not have a lot of time w his OSA..I think oral intubation is fine and trach after would depend on surgical need

I would put an arterial line post induction assuming no cardiac symptoms and good ECHo. I suspect he has some underlying Pul HTN w his uncontrolled OSA and if that were the case then pre induction a line +\- central line depending on severity

2 IVs atleast ofcourse.

 

[urge]

how would you approach this case?

Des....pa.....cito!!!!

 

[deleted875186]

Cervical stenosis does not equal limited ROM necessarily. If airway doesn’t look bad otherwise, no beard, no radiation or anything to make masking difficult, I would be ok with IV induction and intubation, so long as there is a second pair of hands in the room to help with the airway if needed.

 

[Arch Guillotti]

Cervical stenosis does not equal limited ROM necessarily. If airway doesn’t look bad otherwise, no beard, no radiation or anything to make masking difficult, I would be ok with IV induction and intubation, so long as there is a second pair of hands in the room to help with the airway if needed.

Same here

 

[dabears505]

Propofol, six, tube, roc if not nerve monitoring

 

[Consigliere]

how would you approach this case?

I wouldn't. I'd already be home, having figured out how to dump it on the new guy, making him feel grateful toward me for the "great learning experience." That's ninja level turfing, gang.

 

[fakin' the funk]

Love seeing the discussions you geniuses have about cases. So here is one I did a few weeks back.
55y 152kg M scheduled for Maxillectomy, Parotidectomy, neck dissection, and radial arm free flap.
PMH: sub orbital SCC, IDDM (A1c 9.9), NAFLD s/p OLT about 7 years ago, moderate cervical stenosis on MRI, OSA (not on CPAP), HTN on beta blocker, HLD. No documented CAD, COPD, or CVA history.
No known airway involvement by tumor, but physical exam shows Mallampati 4
PSH:OLT, Carpal tunnel, MOHS
AH: No known Anesthetic complications. No airway history on file.
EKG shows SR without any concern for past ischemic changes

how would you approach this case? Did it recently and wondering what I could have done differently (all went well...im a CA1 so looking to see what else is out there)

A lot of weird responses here so I'll take a random tangent: when is ENT gonna put the nasogastric feeding tube in so you can give my dude his tacro/mycophenolate? Or are you gonna give IV?