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Was the appendix perforated?
Laparotomy in profesional Singer
Started by Sleeplessbordernights
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Never could get the patient comfortable with insufflation. The whole case was a PIA - patient and surgeon.
We do like a zillion laparoscopies a year where I am now. Never heard anyone even discuss doing laparoscopies with regional anesthesia.
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Yes, tough the pt was stable
Would have just done this under a spinal w/o sedation, just like a c-section. Hyperbaric Bupivacaine for a more dense block. Yeah, he's got a sick appendix. But we do spinals in sick parturients too. He'd protect his airways best without any sedation on board.
Personally I would never do anything laparoscopic without general and an ETT. If the patient doesn't want it that way, later nerd. I don't HAVE to do your case.
I think OP is discussing open case...not laparoscopic. I hope no one would intentionally suffer doing a regional based laparoscopic case, that's just, no, not worth it ... especially in a septic pt. If you want regional based, go open.
They said they did it lap
Laparatomy not laparoscopic
Always remember that on the stand the lawyers on the opposing side will ask their expert witnesses if you deviated from standard practice. A laparotomy in a septic patient with bowel pathology done under spinal is not standard….especially if things go south.
Why would you insufflate a laparotomy?
Ahhhhhhh, gotcha 👍👍
We do giant CSections under spinal. This is way smaller of a procedure.
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Agree. Spinal for appy isn't my first choice, but if the patient really doesn't want intubation and is okay with being awake for open abd surgery then it is an acceptable option. I would document the discussions made with patient and do it.
I get that but for a ruptured appy????
D
deleted87051
Surgeon once asked me to to an ex lap under local and sedation. He was dead serious.
And?
Nothing. I intubated the patient.
What if the patient “refuses” intubation. Isn’t the number 1 contraindication for not to do a spinal is patient refusal? Shouldn’t that apply here as well? I guess the anesthesiologist can also refuse to do the case too…..
What was the surgeon's rationale? Because jt takes 5 extra minutes to extubate the patient at the end?
At this risk of identifying myself, this reminds me of a story I just heard from a friend who’s a resident at some academic program.
Surgeon thought anesthesia took too long for induction/airway so he requested ICU “pre-intubate” the patient prior to arrival to the OR.
Frankly a case of a spineless anesthesia dept. Of course it was an ugly glidescope intubation that took 30+ minutes.
The patient was sick so he wanted me to give as little as anesthesia as possible and legitimately thought that an ex lap can be done under local and minimal sedation. I ignored him and told him im doing geta. With a pre induction Aline ett and additional access.
It's interesting how some surgeons think!
That's also a spineless ICU department as well. But yeah, that's seriously ****ed and that surgeon needs a good heart to heart about staying in his lane...or just take him out back and beat him with some soap in a sock.
I was split between spineless vs some greedy ICU fellow who wanted an intubation.
We had a heart to heart with NICU, peds anesthesia and peds surgeon when I was training.
The surgeon wanted the patient be ready when he’s ready. Since the peds attendings cover a few hospitals, it will take them too long to setup the room, see the patient, and intubate……. Peds attending wouldn’t have it. Called the other two departments out, why would you subject the patient to an endotracheal tube for hours just to save a few minutes.
I suppose another lesson for me was, they (both NICU and surgery) really think intubation is a benign procedure, that putting a kid “under” is okay, just for convenience. We really need to be patient advocates.
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That's just ridiculous to appease a surgeon. No way this can ever be good care for thr patient.
I feel like there's a word for that...mal-something? Maleficent? Maldistribution? Malcontent? I don't know, but MAL something and it would definitely be said in a courtroom.
Spinal in this patient has concerns for epidural abscess. But I wouldn't be concerned about aspiration for awake patient....so limit the sedation.
I think we have seen many CS where the patient poorly tolerates pulling on the viscera, so I could easily see difficulty with perfect coverage even with a perfect spinal. Especially when they are "gently" tugging on things. There was a good studied that showed increased gastric paresis with gentle versus rough handling of the intestines. So, it does matter.
Finally, an appropriately sized ETT causes less sore throat than a down-sized ETT. I get that we are talking about the vocal cords, but is there evidence that a smaller ETT causes less issues for the vocal cords? (outside of common sense which would have made me doubt the first sentence in this paragraph)
I think we have seen many CS where the patient poorly tolerates pulling on the viscera, so I could easily see difficulty with perfect coverage even with a perfect spinal. Especially when they are "gently" tugging on things. There was a good studied that showed increased gastric paresis with gentle versus rough handling of the intestines. So, it does matter.
Finally, an appropriately sized ETT causes less sore throat than a down-sized ETT. I get that we are talking about the vocal cords, but is there evidence that a smaller ETT causes less issues for the vocal cords? (outside of common sense which would have made me doubt the first sentence in this paragraph)
Smaller tube might be less likely to ding the vocal cords when it is being placed. Good technique and not being forceful with stylette is probably more important. Same with making sure cuff is not inflated on the cords and that it isn't overpressure to mucosa and secured well so it isn't moving up and down the trachea..
Tell me why not.
I think what we're getting at is analagous to putting a spinal in an OB patient who is septic for a c section. A spinal in a healthy individual, parturient, or routine open appy is completely different. You could burn yourself pretty easy. Not to mention if there is a peritoneal process going on, such as in a ruptured appy, it is more difficult to cover with a spinal. OB patients vomit all the time with retraction, now imagine puss and inflammation all over those peritoneal areas instead. Also, if the patient starts vomiting and wont tolerate said surgery, then you're burned sedating or intubating anyways. Then the patient might be acidotic and you cant compensate with ventilatory changes. It's not worth it.
Ehh. I think it's all dogma. So what they are septic. Load them up with fluids and pressers. And if you think they are gonna vomit, give them an anti emetic and a kidney basin. And if they are acidotic, more ways than one to assist with that. Heard of Sodium Bicarb? Now if they lose consciousness from the sepsis, then that's another thing. But you have seen plenty of young septic patients and how well they are able to compensate even when their numbers are completely whack. I have seen a patient with a pH of 6.87 from DKA who was in her 50'that didn't require intubation.
Honestly, we are taught a certain way in this country and we run with it like it's the only way. Maybe I am out of practice since I do mostly CCM, but how are you gonna not be able to cover the area with a spinal due to sepsis? You are injecting local in the spinal space, not directly into the wound or abdomen itself right? So the change in the PH in the abdomen, is irrelevant as I am covering the spinal nerve roots right? Unless the spinal space is infected what's the contraindication? Or worry that it won't work?
I am not convinced.
There is a lot that can be done with spinals. But this is America and we put patients under MACs for hangnails, so......
A relative contraindication of spinal anesthesia is sepsis distinct from the anatomic site of puncture (i.e, chorioamnionitis or lower extremity infection). Just like coagulopathy is. If the patient is on antibiotics and the vital signs are stable I MIGHT be willing to entertain the idea. I also wouldn't give someone sodium bicarb unless they're pH was below 7.1 and by that point you've most likely already intubated the patient. I don't really see the point in making the case harder for yourself, having to multi-task dealing with an awake patient, possible inadequate coverage from your neuraxial, and possibility of the case time going over the duration of your sensory block. There's a difference in a chronically awful diabetic with a pH of 6.87 not requiring intubation, and an acute abdomen in a patient who's pH was 7.3 2 hours ago. I don't see how that anecdote fits this situation at all. If you're willing to put up with all that badness to satisfy a silly patient request props to you. I'm not willing to go out of my way to bend the rules/what I was taught and have experienced.
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Had a patient one timer for abdominal surgery who didn't want to be put to sleep. Did a CSE even. Still had to put him to sleep.
All this to spare the uninformed princess from an ETT? No thanks. They get consented like anyone else to get a tube in their throat, and they get counseled that the likelihood of them dying from their appendicitis is much higher than the likelihood of their voice being injured by the ETT that will be in their throat for an hour.
I find it completely whacky that some of you would do an abdominal case on a septic patient under spinal anesthetic. It reminds me of that case of the guy who underwent open heart surgery under epidural anesthesia. Just because you can do something doesn't make it a great idea.
I read 27 y/o with appendicitis: where is the sepsis? That's what people do when they don't have the ability to manage cases with anything less than en ETT: deflect on (non issues) of infection, epidural abcess, consent etc...
It's a perfectly valid request from a patient to avoid GA and ETT if possible.
I do (or have done) c-sections, hernias, prostatic adenectomies under spinal all the time.
There is absolutely no reason a spinal cannot be attempted for this case with the possibilty to convert to GA if necessary.
It's a perfectly valid request from a patient to avoid GA and ETT if possible.
I do (or have done) c-sections, hernias, prostatic adenectomies under spinal all the time.
There is absolutely no reason a spinal cannot be attempted for this case with the possibilty to convert to GA if necessary.
I wouldn’t hesitate. Sab or CSE should be fine.
You need to read the original post again along with the thread of responses.
“We have a profesional singer whit a bad appy, 8 days of evolution, Healthy 27 year old.”
The OP didn’t specify that he was septic (though it’s not a stretch given the clinical scenario), so earlier in the thread I said that ASSUMING the patient has severe sepsis, would people still do it? And a bunch of people said yes. Even on this page someone, to justify a spinal anesthetic, someone said “So what they are septic. Load them up with fluids and pressers. And if you think they are gonna vomit, give them an anti emetic and a kidney basin. And if they are acidotic, more ways than one to assist with that. Heard of Sodium Bicarb?”
So yeah, no one is deflecting onto anything. There are several people that would manage a severely septic patient who needs pressors, etc with a spinal anesthetic for this case. Are you one of them?
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You said a relative contraindication right?
Honestly, I am just trying to get people to think outside the box in this situation. I have taken care of some ruptured appys but I honestly don't remember one who was that severely septic that they were that decompensated. A ruptured small or large bowel, yeah. A ruptured appendix? In a young person? Patient is 27. I have seen them walk around the next day and out of hospital within two.
Yes, it's gonna be more challenging, but it can be done is all I am saying. It can be started it out that way, and if it gets bad then tube him. I also don't see why the attending wanted to try such a high level of spinal in this patient anyway.
Ehh, I am bored, but it can be done. I would attempt it.
I am. Because you can load him up with all the above stuff by lining them up properly, preloading them and continuing to load them in the OR and talking to them about the fact that the they may still need an ETT in the end, but we can try it this way first.
The fact that you’re equating a PNB for postop analgesia to securing an airway before a bowel case is bizarre to me.
I would also ask you to consider the fact that surgeons operate on the knees of professional athletes, the vocal cords of singers, etc all the time, yet you're scared to perform a routine, safe procedure (intubation) that you do literally every day, that represents the standard of care, that is what you would do in any other patient with similar pathology, all due to the fear of the 0.00000000000000001% chance you permanently damage their voice? Yikes.
This just really drives home the point that you never want to be a "VIP" when you're getting healthcare. When you are suddenly deemed more important than the average Joe, peoples' judgment gets clouded, and suddenly you're getting substandard care because you are getting treated differently than the million other patients that pass through the doors.
Problem is the pt has done their own "research" and is now asking for less than standard of care. They are specifically asking for a VIP treatment.
