Laparoscopic Banding

Started by militarymd
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militarymd

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30 something year old overweight lady undergoes lap band under ga.

Preop Labs...normal.

PMHx: HTN being treated with hctz

NKDA

Concerned about PONV.

Given Scop patch and decadron preop...and zofran in OR.

Case was unremarkable...other than bradycardia during insufflation requiring atropine.

Post Op:

In recovery...over one hour before emergence from GA enough for OA to come out.

Vitals stable...Sats 99% on NC.

Patient refuses to turn to the left...and stares at her right hand screaming and crying.

Thoughts on what to do next.
 
militarymd said:
30 something year old overweight lady undergoes lap band under ga.

Preop Labs...normal.

PMHx: HTN being treated with hctz

NKDA

Concerned about PONV.

Given Scop patch and decadron preop...and zofran in OR.

Case was unremarkable...other than bradycardia during insufflation requiring atropine.

Post Op:

In recovery...over one hour before emergence from GA enough for OA to come out.

Vitals stable...Sats 99% on NC.

Patient refuses to turn to the left...and stares at her right hand screaming and crying.

Thoughts on what to do next.
Click to expand...
-scop patch off. give physostigmine.
-Additional history of med/druguse, or psych hx?
-wait.
 
This sounds like an interesting case, Mil. Can someone go the extra mile on this one and give a bit of the thought process as this case discussion progresses? I can understand many of these discussions, but this one seems more complex than an infection and fever post op...not to say that's not complex. I usually don't ask in the midst of these discussions, but I'm curious:

Is the patient in pain or is it lack of feeling altogether that causes screaming and crying? (I suppose that's the first thing I'd ask: wussup?)

Is the patient unable to roll left, or look left, or just doesn't want to?

Does the physostigmine reverse something like neo? (Never mind, I'll look this one up...google).

Thx,
D712
 
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dr doze said:
-scop patch off. give physostigmine.
-Additional history of med/druguse, or psych hx?
-wait.
Click to expand...

My partner did exactly that after the first hour.

After the second hour, when things weren't improving...he called me to see the patient...

no history of med/drug use
negative psych hx.

Any thoughts on what to do next?
 
doctor712 said:
This sounds like an interesting case, Mil. Can someone go the extra mile on this one and give a bit of the thought process as this case discussion progresses? I can understand many of these discussions, but this one seems more complex than an infection and fever post op...not to say that's not complex. I usually don't ask in the midst of these discussions, but I'm curious:

Is the patient in pain or is it lack of feeling altogether that causes screaming and crying? (I suppose that's the first thing I'd ask: wussup?)

Is the patient unable to roll left, or look left, or just doesn't want to?

Does the physostigmine reverse something like neo? (Never mind, I'll look this one up...google).

Thx,
D712
Click to expand...

Can't tell if she is in pain....she's just screaming incoherently and crying...looking at her right hand...won't follow directions.
 
OK,
R/O correctable causes of post-op delirium (hypothermia, hypoxia, full bladder...)
Make sure there are no obvious neurological focal signs
Then just sedate the patient and wait.
Once the agitation is controlled you will be able to examine the patient and find out if there is real pain or tenderness.


militarymd said:
Can't tell if she is in pain....she's just screaming incoherently and crying...looking at her right hand...won't follow directions.
Click to expand...
 
militarymd said:
30 something year old overweight lady undergoes lap band under ga.

Preop Labs...normal.

PMHx: HTN being treated with hctz

NKDA

Concerned about PONV.

Given Scop patch and decadron preop...and zofran in OR.

Case was unremarkable...other than bradycardia during insufflation requiring atropine.

Post Op:

In recovery...over one hour before emergence from GA enough for OA to come out.

Vitals stable...Sats 99% on NC.

Patient refuses to turn to the left...and stares at her right hand screaming and crying.

Thoughts on what to do next.
Click to expand...

I'm going with the above, plus the later physostigmine (sure it wasn't pyridostigmine?), stirring something up in the CNS ..... and/or ..... she's extremely succeptible to post-insufflation diaphragmatic pain referred up to the shoulder area ????

Were the arms tucked or out ... if out, were they greater than 90 degrees for too long?
 
Last edited:
militarymd said:
My partner did exactly that after the first hour.

After the second hour, when things weren't improving...he called me to see the patient...

no history of med/drug use
negative psych hx.

Any thoughts on what to do next?
Click to expand...

I would try some fentanyl, check blood sugar, some labs, assume oxygen sats are OK. If labs are OK and fentanyl doesn't do the trick. ...refusing to turn to the left... Any other focal signs? weakness? Repeat physostigmine if fails...

I'm thinking some type of acute neurologic event and getting real nervous.
 
Last edited by a moderator:
DreamMachine said:
Start by looking up "post-operative delirum" and "anticholinergic syndrome." 🙂
Click to expand...

Gotcha DreamM. The thinking is delirium at this point, not pain, I (superficially) see. Anticholinergic syndrome because of Scop and Atropine. And the physo is to counter. And it's not working.

I'll take a peak at Post Op Delirium in books today and watch along as the thread progresses...

Thx,
D712
 
militarymd said:
30 something year old overweight lady undergoes lap band under ga.

Preop Labs...normal.

PMHx: HTN being treated with hctz

NKDA

Concerned about PONV.

Given Scop patch and decadron preop...and zofran in OR.

Case was unremarkable...other than bradycardia during insufflation requiring atropine.

Post Op:

In recovery...over one hour before emergence from GA enough for OA to come out.

Vitals stable...Sats 99% on NC.

Patient refuses to turn to the left...and stares at her right hand screaming and crying.

Thoughts on what to do next.
Click to expand...

Zoolander syndrome, nasty nasty disease.
 
DreamMachine said:
Actually, had a similar case. Anticholinergic syndrome was suspected. Physostigmine was given and nothing happened.

Used a couple mLs of propofol. She took a nap (of course not apneic) and woke up 15 minutes later completely normal.

Try a little propofol...
Click to expand...

4 hours in the recovery....still the same....

All labs normal....
 
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dr doze said:
I would try some fentanyl, check blood sugar, some labs, assume oxygen sats are OK. If labs are OK and fentanyl doesn't do the trick. ...refusing to turn to the left... Any other focal signs? weakness? Repeat physostigmine if fails...

I'm thinking some type of acute neurologic event and getting real nervous.
Click to expand...


thank GOD....there is a Doctor in the house...

Are you suggesting we perform a brief focused Neuro Exam on the patient...the kind that of stuff that is taught in medical school and internship?
 
militarymd said:
thank GOD....there is a Doctor in the house...

Are you suggesting we perform a brief focused Neuro Exam on the patient...the kind that of stuff that is taught in medical school and internship?
Click to expand...

and then follow up with perhaps a list of differential diagnosis....

and follow up with tests to confirm or rule out the suspected diagnosis...


then either prescribe a treatment and/or obtain specialized consultation....


the sort of stuff that doctors do?
 
militarymd said:
and then follow up with perhaps a list of differential diagnosis....

and follow up with tests to confirm or rule out the suspected diagnosis...


then either prescribe a treatment and/or obtain specialized consultation....


the sort of stuff that doctors do?
Click to expand...

or we could just give some drugs...and see what happens...and then give some other drugs...and wait some more to see if things get better...

even though it's something that we don't frequently see...and aren't sure what it is?
 
militarymd said:
or we could just give some drugs...and see what happens...and then give some other drugs...and wait some more to see if things get better...

even though it's something that we don't frequently see...and aren't sure what it is?
Click to expand...

Yea, sure I like this option.

Start with benadryl.

Torticollis???????

If it doesn't work, then you can move on.
 
I hate the hole nausea culture in anesthesia. I wonder if scop, decadron, and zofran weren't she would have been fine.

You are probably going to have to wait it out. No more drugs for her other than toradol.
 
May be nothing but I will ask, how does her right hand look?

Positioning injury? Was the IV in that arm (maybe compartment syndrome)?

Is she answering questions appropriately but just screaming about her right hand?
 
urge said:
I hate the hole nausea culture in anesthesia. I wonder if scop, decadron, and zofran weren't she would have been fine.

You are probably going to have to wait it out. No more drugs for her other than toradol.
Click to expand...

I'm with you....
 
potentagent said:
May be nothing but I will ask, how does her right hand look?

Positioning injury? Was the IV in that arm (maybe compartment syndrome)?

Is she answering questions appropriately but just screaming about her right hand?
Click to expand...

Her right looks fine.

Not answering questions or following directions.
 
Coastie said:
Did anyone do a neuro exam?

edit: gotta read the rest of the thread before responding
Click to expand...

I got involved between hours 3 and 4.

My exam:

Patient is obviously "awake", but appears delirious. She opens her eyes to voice, but does not follow commands.

She intermittently stares at her right hand (open and closed) and screams incoherently.

She does not turn her head to the left...and when you manually try to turn it to the left, she resists.

Vitals are stable...Sats are 100%...Afebrile.

Left arm is limp...and does not with draw to pain....but if you hold her left hand over her head and drop it...it does move enough to not land on her face.

Both lower extremities are rigid...so unable to check DTRs

Toes are both down going.

pupils are mid sized and equal and reactive to light...although it is difficult to see because she squints when you shine the light (fenix 120 lumen) in her eyes....

Unable to perform much else on a neuro exam because the patient won't follow directions.


Possible list of diagnoses:

central anticholinergic syndrome - high on my list early on, but starting to go down

ischemic injury to the central nervous system - unlikely based on her history and presentation, but certainly a possibility

other drug effects - I was leaning in that direction

patient is crazy and faking for secondary gain - I was leaning in that direction



Based on our list...we ordered a stat head CT to rule out any grossly fixable cause of this in her head, but I didn't expect to find anything....

I asked for a urine drug screen...but it was never done.
 
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militarymd said:
I got involved between hours 3 and 4.

My exam:

Patient is obviously "awake", but appears delirious. She opens her eyes to voice, but does not follow commands.

She intermittently stares at her right hand (open and closed) and screams incoherently.

She does not turn her head to the left...and when you manually try to turn it to the left, she resists.

Vitals are stable...Sats are 100%...Afebrile.

Left arm is limp...and does not with draw to pain....but if you hold her left hand over her head and drop it...it does move enough to not land on her face.

Both lower extremities are rigid...so unable to check DTRs

Toes are both down going.

pupils are mid sized and equal and reactive to light...although it is difficult to see because she squints when you shine the light (fenix 120 lumen) in her eyes....

Unable to perform much else on a neuro exam because the patient won't follow directions.


Possible list of diagnoses:

central anticholinergic syndrome - high on my list early on, but starting to go down

ischemic injury to the central nervous system - unlikely based on her history and presentation, but certainly a possibility

other drug effects - I was leaning in that direction

patient is crazy and faking for secondary gain - I was leaning in that direction



Based on our list...we ordered a stat head CT to rule out any grossly fixable cause of this in her head, but I didn't expect to find anything....

I asked for a urine drug screen...but it was never done.
Click to expand...

The sevo was actually turned on, correct? And no ketamine used. Was a BIS used?
 
:poke:

Planktonmd said:
OK,
R/O correctable causes of post-op delirium (hypothermia, hypoxia, full bladder...)
Make sure there are no obvious neurological focal signs
Then just sedate the patient and wait.
Once the agitation is controlled you will be able to examine the patient and find out if there is real pain or tenderness.
Click to expand...

militarymd said:
thank GOD....there is a Doctor in the house...

Are you suggesting we perform a brief focused Neuro Exam on the patient...the kind that of stuff that is taught in medical school and internship?
Click to expand...
 
Since this sounds like a recent case where I had a patient die immediately postoperatively from an embolic stroke, I am really interested if the CT Head shows anything. Ours did, STAT to interventional neurorad within the window for thrombolytic therapy, but he still died of massive cerebral edema. You're outside the window now, unfortunately.
 
urge said:
I hate the hole nausea culture in anesthesia. I wonder if scop, decadron, and zofran weren't she would have been fine.
Click to expand...

So you don't mind if someone who has just had a lap band placed vomits postoperatively?

It's not uncommon for us to do these cases with TIVA + dexamethasone + droperidol + tropisetron + high FiO2 - all to avoid PONV (well POV really the nausea isn't really the issue).
 
pushthesux said:
Since this sounds like a recent case where I had a patient die immediately postoperatively from an embolic stroke, I am really interested if the CT Head shows anything. Ours did, STAT to interventional neurorad within the window for thrombolytic therapy, but he still died of massive cerebral edema. You're outside the window now, unfortunately.
Click to expand...

You saw evidence of an embolic stroke on CT within 3 hrs? That's a pretty special CT scanner you got there.
 
Of course do a physical exam.

Most likely stuff is anti-cholinergc syndrome.

However, I am suspecting a dystonic reaction of some sort. Tardive dyskinesia vs. dystonic torticollis,etc. Yes, these things are MORE common with Metoclompramide,however, can occur with ondasetron as well.

Suggestion: Benztropine or diphenhydramine to start.

check it out
http://www.anesthesia-analgesia.org/cgi/content/full/96/5/1374


militarymd said:
I got involved between hours 3 and 4.

My exam:

Patient is obviously "awake", but appears delirious. She opens her eyes to voice, but does not follow commands.

She intermittently stares at her right hand (open and closed) and screams incoherently.

She does not turn her head to the left...and when you manually try to turn it to the left, she resists.

Vitals are stable...Sats are 100%...Afebrile.

Left arm is limp...and does not with draw to pain....but if you hold her left hand over her head and drop it...it does move enough to not land on her face.

Both lower extremities are rigid...so unable to check DTRs

Toes are both down going.

pupils are mid sized and equal and reactive to light...although it is difficult to see because she squints when you shine the light (fenix 120 lumen) in her eyes....

Unable to perform much else on a neuro exam because the patient won't follow directions.


Possible list of diagnoses:

central anticholinergic syndrome - high on my list early on, but starting to go down

ischemic injury to the central nervous system - unlikely based on her history and presentation, but certainly a possibility

other drug effects - I was leaning in that direction

patient is crazy and faking for secondary gain - I was leaning in that direction



Based on our list...we ordered a stat head CT to rule out any grossly fixable cause of this in her head, but I didn't expect to find anything....

I asked for a urine drug screen...but it was never done.
Click to expand...
 
I skimmed the thread. I dont think anyone mentioned steroid psychosis. Obviously highly unusual but I would consider it.

my first thought was post op delirium (classic ketamine behavior from my experience)
then anticholinergic
then extrapyramidal
then CVA (lower many because of age). Neglect is so pathognomonic

To me the most important info was 1 hr to wake up- super bizarro in young pt, even if morbidly obese.

Neglect

Neglect

Arm drop test

Being a former paramedic, the arm drop test really really bothers me and makes me think psych which is always high on my list (for this reason, I always make it a diagnosis of exclusion- way last or I really favor it 🙂 )

What MAPs did she have during the case. Watershed CVA? Embolic through R heart lesion?

Common things happen commonly which is way cookbook medicine and such works most of the time. However, in this case, waiting hours trying different therapies could lead to huge morbidity in a young pt with an embolic CVA...
 
Planktonmd said:
:poke:
Click to expand...

True Plank, I thought the same thing about MilMD's post, because I had read yours already. However, he probably ignored your post given the well-known dispute between you two, knowing someone else would eventually say the same thing.

Interesting case, nonetheless. It's what I like about this forum.
 
pushthesux said:
Since this sounds like a recent case where I had a patient die immediately postoperatively from an embolic stroke, I am really interested if the CT Head shows anything. Ours did, STAT to interventional neurorad within the window for thrombolytic therapy, but he still died of massive cerebral edema. You're outside the window now, unfortunately.
Click to expand...

Bayes theorem....pre test probability is very low....you know the data on periop ischemic strokes in non cardiac..non carotid surgery as well as I do....especially if you had a case recently like this.

Ischemic strokes...UNLESS HUGE is NOT likely to show much of anything.

I personally would be looking for bleeds...unexpected tumors which developed changes during surgery due to hypercarbia (insufllation) , fluids...or whatever else that happens during surgery.


But the CT was normal.
 
rsgillmd said:
True Plank, I thought the same thing about MilMD's post, because I had read yours already. However, he probably ignored your post given the well-known dispute between you two, knowing someone else would eventually say the same thing.

Interesting case, nonetheless. It's what I like about this forum.
Click to expand...

he's on ignore for a while now. I haven't read any of his posts since I put him on ignore unless someone quotes him....so please don't.
 
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After the CT...neurology was consulted....

By the time the neurologist showed up....she started ignoring her right hand...

MRI..echo...MRA...million dollar work ensued in the next 24 hours....

ALL normal.

psych consult pending.
 
Planktonmd said:
😀
So, What's the diagnosis Dr. House?
I know: It is a very obvious case of Alice in Wonderland syndrome.
I can't believe everyone missed it.
Click to expand...

You are such a tool. After they gave you a negative ct scan and tell you that psych was consulted you start with "so obvious I cannot believe everyone missed this"....

Sherlock, this is as obvious as calling a baby's sex after seeing their genitals.
 
urge said:
You are such a tool. After they gave you a negative ct scan and tell you that psych was consulted you start with "so obvious I cannot believe everyone missed this"....

Sherlock, this is as obvious as calling a baby's sex after seeing their genitals.
Click to expand...

👍 :laugh:

My contribution to the clinical portion of this thread: (1) make sure she can continue to support her airway, (2) give her a big 'ol dose of Ativan, (3) let her sleep it off.

You don't need to call psych "STAT". I've had people wig-out on Phenergan before. Once they sleep it off, they're better.

-copro
 
Exactly! 👍
So you actually agree with me that this is Alice in wonderland syndrome?
I actually was joking but who knows maybe It is AIWS!
I actually think this was a simple case of post-operative delirium that someone got too excited about and made it sound too complicated which ended costing the system a few thousand dollars.
Post-operative delirium can manifest in so many different ways including what appears as focal signs and abnormal movements that could last for days in some cases. The only common thing between all these manifestations is that they are all self-limited.
And the other characteristic of post operative delirium is that it is certainly more common than AIWS.

(Actually I think that AIWS itself could be a symptom of post-op delirium but I would leave this to our psych colleagues to sort out).





urge said:
You are such a tool. After they gave you a negative ct scan and tell you that psych was consulted you start with "so obvious I cannot believe everyone missed this"....

Sherlock, this is as obvious as calling a baby's sex after seeing their genitals.
Click to expand...
 
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