Laparotomy in profesional Singer

[Urzuz]

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.

True, but if a regular schmuck says they’re scared of going to sleep for their appendectomy because they may never wake up after and asks to be awake for it, you would counsel them that the chance of them not waking up is pretty much 0%, and going to sleep is the safer option. Do the same thing with the VIP - the chance of their voice being permanently damaged is pretty much 0%, and going to sleep is the safest option.

Don't get me wrong - I think that the patient's concern is legitimate. But it is your job as the expert to counsel them that despite what they may have read or heard from their friends, the incidence of permanent voice damage from an intubation for a case that is <1 hour is pretty much 0% (I did a cursory search for an actual number and can't even find one, probably reflecting how rare it actually is).

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[MirrorTodd]

True, but if a regular schmuck says they’re scared of going to sleep for their appendectomy because they may never wake up after and asks to be awake for it, you would counsel them that the chance of them not waking up is pretty much 0%, and going to sleep is the safer option. Do the same thing with the VIP - the chance of their voice being permanently damaged is pretty much 0%, and going to sleep is the safest option.

Don't get me wrong - I think that the patient's concern is legitimate. But it is your job as the expert to counsel them that despite what they may have read or heard from their friends, the incidence of permanent voice damage from an intubation for a case that is <1 hour is pretty much 0% (I did a cursory search for an actual number and can't even find one, probably reflecting how rare it actually is).

I'd get a damn good detailed history about their families reactions to anesthesia in the past. I feel like that particular phrase is a dead giveaway for MH. I remember there was a video about some MMA fighter a while ago who basically said the same thing to an Anesthesiologist and you can guess what happened.

But I get what you are saying.

 

[nimbus]

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.

The comparison is relevant because you are risking someone’s livelihood. The incidence of hoarseness is very high after intubation. Fortunately it is usually not permanent. But for a professional singer, residual subtle differences may be important. I personally don’t think appendectomy under spinal anesthesia is outside the standard of care. Just because it’s not the norm in the USA doesn’t mean it’s not reasonable.

https://www.longdom.org/open-access/comparison--between--spinal--anesthesia--vs--general--anesthesia-in-patients-undergoing--open--appendectomy-for-acute--a.pdf

 

[pgg]

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.

There's a difference between a 27 yo appy "bowel case" as described in the OP and a 70 yo septic SBO "bowel case" ....

A spinal is a fine anesthetic. What do you think is going to happen? That this awake 27 yo is going to get a spinal and suddenly become obtunded and then aspirate? He's been laying around for eight days ... eating, sleeping, watching TV, and yet he's managed to not aspirate even though for eight days he hasn't had a tube in his trachea. As long as you keep the spinal level below, oh, C5 or so, he's going to lay there, awake, not aspirating, for a 30 minute open appy.

Everything we do is a balance of risk/benefit. You're grossly overestimating the risk of a spinal in this particular patient.

 

[deleted875186]

I would entertain regional for an elective case, no way for an appendectomy.

I find the discussion interesting about ETT and airway injuries. Sore throat is not damage to the vocal cords, patient should have been educated. Smaller ETT would help only if the glotic opening is small or there is difficulty passing a tube, otherwise it may just cause more sore throat since the cuff needs more volume and pressure to make a deal. Patient really should have been asking for the most experienced operator to do the intubation.

 

[IlDestriero]

Never in my life I will try something like this again, was awful

It sounds like your attending tried to make it a lot more complicated and dangerous than it had to be. Spinal is reasonable for an uncomplicated appy with no sedation, maybe a couple of midaz. Now there’s dead bowel and gangrene or whatever, so tube time. Learn from the bad decisions of your attending.

 

[IlDestriero]

Maybe I should have added fent, as I only used ropi and morphine

Fent might have helped make a denser block, with 2cc 0.75% bupiv w/ dextrose.

 

[chocomorsel]

There's a difference between a 27 yo appy "bowel case" as described in the OP and a 70 yo septic SBO "bowel case" ....

A spinal is a fine anesthetic. What do you think is going to happen? That this awake 27 yo is going to get a spinal and suddenly become obtunded and then aspirate? He's been laying around for eight days ... eating, sleeping, watching TV, and yet he's managed to not aspirate even though for eight days he hasn't had a tube in his trachea. As long as you keep the spinal level below, oh, C5 or so, he's going to lay there, awake, not aspirating, for a 30 minute open appy.

Everything we do is a balance of risk/benefit. You're grossly overestimating the risk of a spinal in this particular patient.

We are so in the minority here. I am with you. There are so many ways to skin a cat. We as anesthesiologists should know this.

 

[Urzuz]

There's a difference between a 27 yo appy "bowel case" as described in the OP and a 70 yo septic SBO "bowel case"

And there's a difference between a slightly inflamed, soft-call appendicitis (which a recent study out of NEJM shows you can probably manage with just antibiotics) and one that the original post describes as a "bad appy" that has been brewing for 8 days (and who, by the way, ended up with an ileostomy).

Look no further than what the OP said his experiences with the case were like. "It was awful", "Never in my life I will try something like this again, was awful"

Learning from others' experiences is what M&M is all about, but if for some reason you think you're smarter/better than the OP and you would want to venture down the same path expecting significantly different results, go for it.

 

[chocomorsel]

Why do it laparoscopic? Did we ask to do it open?

I honestly thought it was open myself.

 

[chocomorsel]

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.

I wonder how pregnant woman handle it. What kind of surgery? Are people just wimps? And pregnant women not?

 

[chocomorsel]

Never in my life I will try something like this again, was awful

Never in my life I will try something like this again, was awful

What was awful? Patient was morning and moving? Screaming? Pulling at drapes? Vomiting everywhere?

 

[deleted875186]

I wonder how pregnant woman handle it. What kind of surgery? Are people just wimps? And pregnant women not?

Only time during a C section women predictably get nauseous is if the OB inverts and pushes in uterus, so I can imagine if a general surgeon is manipulating the bowels the whole surgery it probably provoked nausea.

 

[nimbus]

These folks did 231/342 appy’s with spinal anesthesia.

https://www.longdom.org/open-access/comparison--between--spinal--anesthesia--vs--general--anesthesia-in-patients-undergoing--open--appendectomy-for-acute--a.pdf

 

[Urzuz]

These folks did 231/342 appy’s with spinal anesthesia.

https://www.longdom.org/open-access/comparison--between--spinal--anesthesia--vs--general--anesthesia-in-patients-undergoing--open--appendectomy-for-acute--a.pdf

You don't see a problem with using retrospective data, where in one of their first paragraphs they say "The anesthesia used was neuro-axial (spinal) in one group and balanced general in the other, depending on the preference of the anesthesiologist or the suspicion of complicated conditions such as peritonitis, contraindications to any of the techniques or failure in the block that forced conversion to general" ? You see this as being applicable to the case presented by the OP? They didn't have the hubris to do a spinal anesthetic in a patient who has peritoneal symptoms or a potentially ruptured appendix.

 

[nimbus]

You don't see a problem with using retrospective data, where in one of their first paragraphs they say "The anesthesia used was neuro-axial (spinal) in one group and balanced general in the other, depending on the preference of the anesthesiologist or the suspicion of complicated conditions such as peritonitis, contraindications to any of the techniques or failure in the block that forced conversion to general" ? You see this as being applicable to the case presented by the OP? They didn't have the hubris to do a spinal anesthetic in a patient who has peritoneal symptoms or a potentially ruptured appendix.

This is what the OP wrote. IMO the attending had a reasonable plan.

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?