Laparotomy in profesional Singer

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Sleeplessbordernights

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This is happening right now. Im on call. We have a profesional singer whit a bad appy, 8 days of evolution, Healthy 27 year old. As im discussing the case with him he begs us not to intubate, as it will damage his singing ability. I discussed the case with my attending, she says we will try a T4 spinal hope for the best and if he does not tolerate we will intubate, my attending does not like lmas. What do you think?
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Had a similar situation earlier this year with a professional singer as well.

Just Glidescope/McGrath and downsize your ETT to be extra safe and it will all go fine.
 
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Will the surgeon do it open? I wouldn't spinal and sedate even an open if it's been brewing for 7 days. The chance of aspiration is high. Also lma is risky with bowel problems like this, and no chance stuffing something down blind is less likely to cause damage as eat with glide.
 
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Sleeplessbordernights said:
This is happening right now. Im on call. We have a profesional singer whit a bad appy, 8 days of evolution, Healthy 27 year old. As im discussing the case with him he begs us not to intubate, as it will damage his singing ability. I discussed the case with my attending, she says we will try a T4 spinal hope for the best and if he does not tolerate we will intubate, my attending does not like lmas. What do you think?
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Is this an open appy? Spinal with *0* sedation would be fine I suppose…
 
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I’ve always wanna do an abd case under spinal.

I think if the patient asked explicitly not to be intubated, then I’d try my best to follow his wishes, within reasons.

Also if he had thought about this, there is always a chance if anything, I do mean anything, happen to his voice….. he can come back and bite you.
 
IMGASMD said:
I’ve always wanna do an abd case under spinal.

I think if the patient asked explicitly not to be intubated, then I’d try my best to follow his wishes, within reasons.

Also if he had thought about this, there is always a chance if anything, I do mean anything, happen to his voice….. he can come back and bite you.
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Lets see how it goes
 
If you can do a csection under spinal, open appy should be fine with a good surgeon and a motivated patient. You can start that way and convert to GETA if necessary.
 
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He won’t be singing if he aspirated and spends a week in the ICU on a ventilator and then develops subglottic stenosis.

I would just say that irrational anxiety about tiny risks can make people take much higher risks leading to a potentially more devastating outcome. If you think a spinal would work then fine but make it clear to him that you are in charge of keeping him alive (focus on the highest value and priority) and that a controlled glide scope induction with a 6.0 tube is probably your safest chance for zero complications.
 
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Ive done a spinal and mild sedation for open appy in a bad respiratory cripple. Went fine. N=1
 
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For something that's been brewing, tubey tube... Not worth the risk of intubating an aspirating airway if anything to go awry, especially for someone who is concerned about their money maker. Sure spinal if he refuses anything else
 
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Depends how bad the soiling is, but I'd have 0 qualms giving a spinal and going open, with a clear pathway and consent for conversion to GA if poorly tolerated. Why are we all wanting to sedate this gentleman?
 
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woopedazz said:
Depends how bad the soiling is, but I'd have 0 qualms giving a spinal and going open, with a clear pathway and consent for conversion to GA if poorly tolerated. Why are we all wanting to sedate this gentleman?
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SAB ought to be fine. Not sure what the concern is with a little sedation either - unless we're talking propofol infusion etc. A little midaz should be fine.

N=1 on a laparoscopy with an epidural years ago. Never ever again.
 
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woopedazz said:
Depends how bad the soiling is, but I'd have 0 qualms giving a spinal and going open, with a clear pathway and consent for conversion to GA if poorly tolerated. Why are we all wanting to sedate this gentleman?
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Go big or go home, Am I ‘Ight?

 
jwk said:
SAB ought to be fine. Not sure what the concern is with a little sedation either - unless we're talking propofol infusion etc. A little midaz should be fine.

N=1 on a laparoscopy with an epidural years ago. Never ever again.
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May I ask why?
 
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Much of the developing world does major abdominal surgery under spinal, because it's a $2 anesthetic that doesn't need an anesthesia machine. It goes fine with motivated patients and surgeons who don't dawdle around. An open appy in a healthy 27 yo is a chip shot.
 
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pgg said:
Much of the developing world does major abdominal surgery under spinal, because it's a $2 anesthetic that doesn't need an anesthesia machine. It goes fine with motivated patients and surgeons who don't dawdle around. An open appy in a healthy 27 yo is a chip shot.
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Anything below but not including the diaphragm can be done with a spinal or epidural.
 
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NICMAN said:
He won’t be singing if he aspirated and spends a week in the ICU on a ventilator and then develops subglottic stenosis.

I would just say that irrational anxiety about tiny risks can make people take much higher risks leading to a potentially more devastating outcome. If you think a spinal would work then fine but make it clear to him that you are in charge of keeping him alive (focus on the highest value and priority) and that a controlled glide scope induction with a 6.0 tube is probably your safest chance for zero
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THIS. A million times over. Undersizing the tube, lubricating it, and even extubating deep to avoid the vocal cords banging the tube during coughing is the best approach in my opinion.
 
Going to lengths for something like this to borderline unsafe is dumb IMO. Bad stuff happens when you try too much to accommodate. Put the tube in a bottle of warm saline for 30 minutes prior, use a 6.5 tube, lube the tip and balloon of the tube. Glidescope and be gentle, only dl and intubate with full paralysis, don't overinflate the balloon. You worried he's going to sue you for his voice being hoarse and requiring a breathing tube for an emergent abdominal case? No chance of winning that. You know what also ruins someone's ability to sing? Aspiration.
 
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People saying this guys gonna aspirate and die under a non-sedated spinal: Can you please explain your rationale? Also are all of your cesareans RSI GAs? 😜
 
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woopedazz said:
People saying this guys gonna aspirate and die under a non-sedated spinal: Can you please explain your rationale? Also are all of your cesareans RSI GAs? 😜
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Not that I think he’s going to necessarily aspirate and die, but to equate a C-section where the mom is stable (even if baby is having decels) to a “bad appy” (as the OP called it) is comparing apples to oranges. People can be sick as **** from bad appendicitis (think severe sepsis) and doing a severely septic patient with a potentially perforated appendix under spinal anesthesia without a controlled airway seems pretty stupid.

😜
 
Urzuz said:
Not that I think he’s going to necessarily aspirate and die, but to equate a C-section where the mom is stable (even if baby is having decels) to a “bad appy” (as the OP called it) is comparing apples to oranges. People can be sick as **** from bad appendicitis (think severe sepsis) and doing a severely septic patient with a potentially perforated appendix under spinal anesthesia without a controlled airway seems pretty stupid.

😜
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Yeah I wouldn’t do a spinal on a frankly septic patient.
 
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Spinal with minimal or no sedation is fine, gentle intubation geta is fine. Everything has its risks. Just know what the risks are and be vigilant about avoiding them. Document the risk discussions with the patient and let them choose.
 
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IMGASMD said:
@Sleeplessbordernights, don’t leave us hanging now!
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Sorry to leave you hanging I was pretty beat up after this night, the appy finished at 2 and we still had a bka pending, anyway, Yeah it was awful. I did the spinal to T3 with Ropi and morphine, plus sedation with midaz and precedex. Everything went fine the first hour or so but they had to perform and ileostomy a lot of tugging, I said **** it but my attending did not allow it, so I had to give prop bolus, fortunately the surgeons Were very fast but i fenta it was an awful experience which i would never repeat.
 
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ProwlerturnGas said:
This. I think much of the vomiting and such are from rough emergence coughing choking etc.
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In addition, what is stopping one from putting down an OG and taking as much out of the stomach volume as possible prior to emergence?

Caveat: as the OP has provided more information about this particular case, it is clear that this is not a “routine appy”. I can’t think of a time in my career where an appendicitis has turned into an ileostomy. Obviously a pretty rare occurrence.
But Arch seemed to say that after any appy he would avoid it.
 
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Blockit said:
In addition, what is stopping one from putting down an OG and taking as much out of the stomach volume as possible prior to emergence?

Caveat: as the OP has provided more information about this particular case, it is clear that this is not a “routine appy”. I can’t think of a time in my career where an appendicitis has turned into an ileostomy. Obviously a pretty rare occurrence.
But Arch seemed to say that after any appy he would avoid it.
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Never in my life I will try something like this again, was awful
 
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ProwlerturnGas said:
This. I think much of the vomiting and such are from rough emergence coughing choking etc.
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Right but an awake patient coughing and vomiting has a protected airway. Deep extubation for an acute abd… asking for trouble for minimal gain imo.

Better to wake up with adequate opioid on board.
 
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I deep extubate almost all my young choles and appys and have never had an issue, always place an OG tube and empty the stomach before and after insufflation. If the patient was septic however I would be less enthralled by the idea.
 
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Sleeplessbordernights said:
Never in my life I will try something like this again, was awful
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Your spinal wasn't dense enough. No different than managing a marginal block for a C-section. Which also sucks Not saying that you should try it again, but major abdominal surgery can be done smoothly with an epidural or spinal.
 
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dr doze said:
Your spinal wasn't dense enough. No different than managing a marginal block for a C-section. Which also sucks Not saying that you should try it again, but major abdominal surgery can be done smoothly with an epidural or spinal.
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Maybe I should have added fent, as I only used ropi and morphine
 
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Interesting case. as a CA-3 I participated in an anesthetic an awake, open cholecystectomy on a patient who had a dangerously narrow airway (we had fiberoptic pictures to prove it from the ENT). This person had swallowed bleach as a child and had a ton of internal scarring (though nothing was evidence externally). We ended up doing a mid thoracic epidural, dosed him up heavily and gave remifentanil boluses. THe patient definitely felt a TON of pressure during the case during the retraction. In retrospect we probably could have ran remi at 0.03 to 0.05 and still have had him spontaneously breathinig. We weren't willing to do propofol MAC in case he lost his airway. Perhaps Ketamine @5 and some Dex would have worked too. Dex/Remi is typically what I do for awake TAVRs, though those cases are far less stimulating.
 
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Tell him his music sucks and he wasn’t going to “make it big” anyway. Prop, sux, tube.
 
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SuperHiro said:
Interesting case. as a CA-3 I participated in an anesthetic an awake, open cholecystectomy on a patient who had a dangerously narrow airway (we had fiberoptic pictures to prove it from the ENT). This person had swallowed bleach as a child and had a ton of internal scarring (though nothing was evidence externally). We ended up doing a mid thoracic epidural, dosed him up heavily and gave remifentanil boluses. THe patient definitely felt a TON of pressure during the case during the retraction. In retrospect we probably could have ran remi at 0.03 to 0.05 and still have had him spontaneously breathinig. We weren't willing to do propofol MAC in case he lost his airway. Perhaps Ketamine @5 and some Dex would have worked too. Dex/Remi is typically what I do for awake TAVRs, though those cases are far less stimulating.
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Good case. I have done an open chole and open gastrectomy under epidural (Both 25 + years ago).0.5% bupiv + epi + NaHCO3 + 100ugfentanyl. 2 open appys with Bupi spinals.

Other than a well consented professional vocalist or airway case like yours, I wouldn't do again.
 
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Dr.whom said:
Spinal with minimal or no sedation is fine, gentle intubation geta is fine. Everything has its risks. Just know what the risks are and be vigilant about avoiding them. Document the risk discussions with the patient and let them choose.
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Yes, everything has it risks, but as a physician it's your job to explain your rationale as to what the safest and best option is to a patient if there is a clear choice. Sure, they can choose if all other things are equal, but ultimately I am not going to perform my job below the standard of care just because an uninformed patient is perseverating on a singular part of the anesthetic plan.

Not sure how sick the patient in the original post was, but assuming that you have a perforated appendicitis patient who is severely septic, they don't get to choose their anesthetic at that point. The risk of **** going sideways is too high and the risk of complications (much worse than a potential hoarse voice for a day) are too high. If it's a soft-call appendicitis for someone who is minimally symptomatic - sure, I can give you a neuraxial block and you can sit there while we pluck it out.
 
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