Interesting case

[DenRock]

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Hi all. First post since this went to GasForums.

This past weekend. 80yo AA male, h/o mild CAD, HTN, CRI. Only med is ACE-I. Received from OSH with (presumed) lower GI bleed and H&H of 4.7/14 from said OSH. He is a Jehova's Witness (?sp), and of course refuses all blood products. He gets about 2L NSS at OSH. Plan is to do an ex-lap, probably colectomy. After discussion with surgeon and family, we rush to the OR. Baseline vitals are HR 90s, BP 100s/60s, ECG with nonspecific ST segments. Tolerates induction quite well - Lidocaine 50mg, Fentanyl 100mcg, Etomidate 10mg, Succinylcholine 120mg for RSI. BP drops only to high 80s/40s. I put in a radial A-line and the fluid coming out looks like blood tinged serous fluid. ABP consistent with NIBP. First ABG shows normal acid/base/elecrolytes, and H&H is 3.1/9.

Things go better than I had hoped intraop, using inhalation with isoflurane at about 0.7% expired, FiO2 ~0.6. Surgery does a colectomy after finding colon full of blood. Surgery is adamant that patient be extubated afterward. I argue that he may not fly, and as a result of surgery/anesthesia will have increased work of breathing, thus increasing O2 demand. I reason that O2 content is already so low, that if we eliminate any demand from respiration this will be the only chance this guy has to survive. I win the extubation argument; we take him to ICU intubated, but only temporarily as we are called back to the ICU about 30min post-op to reintubate the patient after surgery extubates him. They started him on Norepinephrine for ABPs in the 60s/20s. Still no real signs of ischemia on ECG, but he does have diminished U/O.

I know he survived to the next day, but I haven't been back to work to follow up on him. Just looking for comments, things I could have done differently. What kind of H&H have you guys seen people survive without getting RBCs?

 

[militarymd]

........and as a result of surgery/anesthesia will have increased work of breathing, thus increasing O2 demand.

Why do you say this? Why would having anesthesia increase your work of breathing??

 

[2ndyear]

Things that increase work of breathing:
Lung recoil, Thoracic cage resistance, abdominal organ displacement, and resistance to airflow.

 

[MD Dreams]

Why did surgery extubate if they had agreed not to?

 

[militarymd]

Things that increase work of breathing:
Lung recoil, Thoracic cage resistance, abdominal organ displacement, and resistance to airflow.

Anesthesia Does not:

1) change lung recoil
2) change thoracic cage resistance
3) change resistance to airflow

Surgery does change pulmonary mechanics.....Anesthesia does not.

 

[Noyac]

There's no way in hell that I would have extubated that pt and i would have made a real fool out of whoever did extubate him by berating him in front of his peers and the staff. I don't mess around with their area of surgery so they had better not mess around with my area of the airway and whether or not the O2 requirements are greater on or off the vent. I have done more than a few of these JW cases with a handful of them dropping their crit's to around 9. They all survived. They were intubated until their Hct was rising and around 16. Epogen for 2 weeks helped. THese fools have no idea what they are talking about and b/c of their lack of knowledge they are trying to kill the pt.

If I sound a little harsh here, you are right. I did a JW dwarf for an anterior and posterior cervical fusion with a starting crit of 34. We stopped the case after the initial anterior portion b/c of profuse bleeding due to poor surgeons. The pt was a difficult airway to top it off and was nasally intubated awake by FOB. We brought the pt to the ICU with a Hgb 3.5 and Hct 11 sedated and intubated with the plan to keep her intubated till the epogen started working and her crit was increasing. Her neck was completely unstable so she was restrained and in a c-collar. The ICU nurse asked me to change out the nasal ETT b/c she was affraid that the pt would get infected from her nasal tube and surgery agreed. I told surgery not no but hell NO. After rounds I got called stat to the ICU. She was extubated. You gotta be F'ing kidding me. I mask her back to the 90's and ask for the airway cart. While someone runs to the OR forhte airway cart I asked how it happened and the RN said that she self extubated. I said WOW thats impressive cause her arms are in restraints and she is paralyzed. It took 3 of us over 45 minutes to reintubate her. If you can imagine the edema in a pt with a crit of 10 from the amount of fluids it took to maintain her BP. Not to mention that her neck is totally unstable with a surgery less than half complete.

OK so I went on a little bit here but there was a huge lack of communication in my case and I assume in your case as well. This ended up almost killing my pt and yours as well. I would have spelled it out to them that the pt remains intubated till his crit is better. No negotiation.

 

[VentdependenT]

holy christ what a nightmare noyac

I would have killed that surgical service

 

[Noyac]

Any Hgb/Hct number chosen is by definition arbitrary and therefore not applicable to all pts. The transfusion trigger of hct 10 is is of historical interest only ( Lundy 1942) and is not supported by contemporary animal or human studies. Critical O2 delivery (DO2crit) is the point at which tissues shift from luxury or flow independent O2 delivery to either flow dependent O2 or dysfunctional delivery. The Hgb at which pts hit the DO2crit is 3-4 gm/dl (Hct 9-12%) is too low b/c this is the point at which cellular shock occurs. Changes in stored bllod alter its ability to transport and release O2. When stored blood is transfused, O2 delivery is either not improved or worsened. This may be due to lack of 2,3 DPG in stored blood which results in RBC' with a higher affinity for O2 therefore, less delivery to the tissue.
In the only large prospective trial of transfusion (Hebert PC et al) in critically ill pts found that those pts transfused less did at least as well or better than those transfused more. Habib et al looked at CPB pts and the incidence of renal failure or dysfunction as it related to intra-op anemia. THey found that if transfusion was initiated to avoid or treat anemia, the renal failure frequency and death risks actually increased. In Hebert's study the incidence of multi system organ failure was worse in the transfused and there was no difference in the death rate and MI rate b/w transfused and not transfused pts.

Just some points to ponder and discuss.