Let’s do another case

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Noyac

Noyac

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Add-on periectal abcess. Healthy Mildly obese 40yo female. She had this same procedure a year ago and ended up in the ICU for 4 days afterwards because of an MH event.
PMH: in significant other than MH. and some scoliosis.
PSH: above
Labs normal
PE: normal

she is extremely anxious since she “almost died” last time she was here.
Questions?
Plan?
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What about a spinal? How bad is the scoliosis? I know some surgeon like to do this prone, can you convince them to do it supine one stirrups?
 
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Noyac said:
Add-on periectal abcess. Healthy Mildly obese 40yo female. She had this same procedure a year ago and ended up in the ICU for 4 days afterwards because of an MH event.
PMH: in significant other than MH. and some scoliosis.
PSH: above
Labs normal
PE: normal

she is extremely anxious since she “almost died” last time she was here.
Questions?
Plan?
Click to expand...

If same facility or able to obtain - check anesthesia records, ask specifics of event.
Preop airway exam. Reassuring then it would be part of my backup plan...which is LMA/ett with prop drip. Primary anesthetic would probably be a versed/spinal with preferred cocktail. If airway doesn’t look good then glidescope/foi as needed then tiva as mentioned.
 
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1) get the room MH proof: remove vaporizers, flush circuit, change CO2 canister, put on the fancy filters, hide sux
2) refresh MH protocol.
3) Spinal, local + propofol gtt +/- LMA, or ETT TIVA depending on the situation.
Some versed for anxiety.
 
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Noyac said:
Add-on periectal abcess. Healthy Mildly obese 40yo female. She had this same procedure a year ago and ended up in the ICU for 4 days afterwards because of an MH event.
PMH: in significant other than MH. and some scoliosis.
PSH: above
Labs normal
PE: normal

she is extremely anxious since she “almost died” last time she was here.
Questions?
Plan?
Click to expand...

Dude, really?? What a softball. So many easy ways to skin this cat. I’m disappointed. Usually you make up better cases than this.

At least tell me she’s therapeutically anticoagulated and anaphylactic to propofol.
 
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I think we could do a lot more cases with 2 of versed, 100 of fentanyl, and 2/kg of ketamine. If it makes you feel better add a pdex infusion.
“It might hurt a bit for a second, you probably won’t remember anything.”

Surg- She’s moving a bit.
Me- Ok, are you done?

I set a lot of peds fractures with midazolam/ketamine.
 
Spinal might be tricky due to anxiety, body habitus, and how quickly you want her out of your PACU.
Propofol induction and add Roc if planning ETT , LMA or ETT depending on situation/preference , Propofol + Nitrous maintenance.
easy.
 
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Surgeons in my place are B@stards for this at 3am. They want em all prone, and they take 2 hours or more sometimes. Its out of control

So remi/prop tube and tiva for me unfortunately
 
2hrs??? Ouch. Hypobaric bupivicaine placed in the prone jacknife position. Propofol infusion so pt doesnt get bored. Our surgeons did it in about 20 min. Stab it, express it, pack it. Sorry you have to suffer through all that.
 
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SaltyDog said:
Dude, really?? What a softball. So many easy ways to skin this cat. I’m disappointed. Usually you make up better cases than this.

At least tell me she’s therapeutically anticoagulated and anaphylactic to propofol.
Click to expand...
You know me better than that. Hang tight bitch.
 
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0kazak1 said:
What about a spinal? How bad is the scoliosis? I know some surgeon like to do this prone, can you convince them to do it supine one stirrups?
Click to expand...
Good question. She is on gabapentin for chronic pain due to spine pathology. For her one child birth the anesthesiologist refused to place an epidural.
I looked at her back and it was typical obese back with a curvature to the left side that I could appreciate but no real difference in her iliac crest level. Very difficult to palpate anything really.

Now what?
 
jeesapeesa said:
If same facility or able to obtain - check anesthesia records, ask specifics of event.
Preop airway exam. Reassuring then it would be part of my backup plan...which is LMA/ett with prop drip. Primary anesthetic would probably be a versed/spinal with preferred cocktail. If airway doesn’t look good then glidescope/foi as needed then tiva as mentioned.
Click to expand...
I reviewed the case a couple days after it happened last year. I remember it well. It was real.
 
Does it concern anyone that she has returned again a year latter for the same issue? Issue being the periectal abscess, not the MH.
 
Noyac said:
Add-on periectal abcess. Healthy Mildly obese 40yo female. She had this same procedure a year ago and ended up in the ICU for 4 days afterwards because of an MH event.
PMH: in significant other than MH. and some scoliosis.
PSH: above
Labs normal
PE: normal

she is extremely anxious since she “almost died” last time she was here.
Questions?
Plan?
Click to expand...

No MH triggering drugs. Flish your machine and place the absorbents in place. Have your MH kit around. Otherwise do your anesthetic any way you want.
 
Noyac said:
Good question. She is on gabapentin for chronic pain due to spine pathology. For her one child birth the anesthesiologist refused to place an epidural.
I looked at her back and it was typical obese back with a curvature to the left side that I could appreciate but no real difference in her iliac crest level. Very difficult to palpate anything really.

Now what?
Click to expand...

If you were going to do neuraxial you shouldn't need something as long acting as an epidural. Get an ultrasound to evaluate back. Place a spinal if u want.
 
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DocVapor said:
What kind of spine pathology? Spina bifida occulta without the hair patch? Previous surgery? Chiari? Repaired meningocele?
Click to expand...
 

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Ok, so... Flog an attempt at a spinal if you’re feeling lucky, or skip it and just do a non-triggering anesthetic. I still don’t see the contra-indication to GA here. Get solid IV access, tube her in case it turns into a fandango or the “abscess” is more than you bargained for.

Or in other words: prop, roc, tube
 
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What's the weirdest thing you could think of? This isn't an abscess alone it's a connection to myelomingocele and she didn't have MH but rather anaphylaxis to latex!?!
And she's not actually a woman but really ffp in disguise!?! Jk
 
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That article on spinals is interesting, however I don't buy it... a 1.5ml 0.5% hyperbaric bupi (7.5mg) spinal lasting 310.5 minutes according to them? That's 6 hours... That's longer than my 12.5-15mg isobaric bupivicaine spinals. I do think a low dose bupi spinal would be good here with 10 min for saddle block, I don't know if i would skimp below 7.5mg, like a cerclage dose.

A mepivicaine spinal is another option, usually a 1.5% mepivicaine with 3.5-4ccs (around 60mg) based on their height. Do this for a lot of knee procedures and the patients are moving their legs in PACU within 3 hours.

Otherwise if neuraxial isn't an option, tube and propofol TIVA with midaz premed, glyco, 20-30mg of ketamine on induction. Don't like the idea of prone LMA in patients with BMI > 35. Also, don't like LMAs in lithotomy (very low lithotomy might be ok) with mildly obese patients, the chance of aspiration is increased and real (there are papers documenting this).
 
Newtwo said:
What's the weirdest thing you could think of? This isn't an abscess alone it's a connection to myelomingocele and she didn't have MH but rather anaphylaxis to latex!?!
And she's not actually a woman but really ffp in disguise!?! Jk
Click to expand...
Oh lord. I wish for the sake of this post it was that interesting.
 
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Planktonmd said:
Spinal might be tricky due to anxiety, body habitus, and how quickly you want her out of your PACU.
Propofol induction and add Roc if planning ETT , LMA or ETT depending on situation/preference , Propofol + Nitrous maintenance.
easy.
Click to expand...
given her 4 days in icu last time, i think i can wait for the spinal to wear off before turfing her out of PACU and I'll take that as a win
 
Hork Bajir said:
Ok, so... Flog an attempt at a spinal if you’re feeling lucky, or skip it and just do a non-triggering anesthetic. I still don’t see the contra-indication to GA here. Get solid IV access, tube her in case it turns into a fandango or the “abscess” is more than you bargained for.

Or in other words: prop, roc, tube
Click to expand...

If there's a better word for a case gone sideways than "fandango," I don't wanna hear about it.
 
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Noyac said:
Does it concern anyone that she has returned again a year latter for the same issue? Issue being the periectal abscess, not the MH.
Click to expand...

She single?


Seriously though, you’re telling me the great @Noyac can’t sneak a 25g into her IT space?? Mr. I used to do 3 landmark celiac plexus blocks before lunch in between cardiac cases.
 
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SaltyDog said:
She single?


Seriously though, you’re telling me the great @Noyac can’t sneak a 25g into her IT space?? Mr. I used to do 3 landmark celiac plexus blocks before lunch in between cardiac cases.
Click to expand...
Those were the days.
But I see my reputation grows. Since I don’t think I actually did 3, maybe 2. ;)
 
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Hork Bajir said:
@Noyac we choose to bring her into the OR and push prop... What happens next? Curious where this is going
Click to expand...
Well, I decided to proceed to the OR after the MH prep. I hadn’t seen the Spine image but had examined her back as I described before. I planned to do a spinal and the surgeon walked into the OR as I was sitting her up. He pulled up the image and waved me over. Basically, he said no way You get this, just put her to sleep. For a minute I almost listened to him but she was sitting up so I gave it a go. 30 seconds laterI laid her down and kicked back with my feet up the rest of the case. THATS A JOKE!
it took me a few minutes but I got CSF by going from right to left at an angle that I have never done before. I was glad to have the images but they were still only somewhat helpful.
So my question is, how many of you would have gone forward with a spinal in this pt and do you make a point to look at any images? What are the risks of blindly probing the spine in this condition? What link could there be btw scoliosis and MH? A quick google search only came up with one case of ptosis, scoliosis and MH. Maybe Blade can find something?
 
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Noyac said:
Well, I decided to proceed to the OR after the MH prep. I hadn’t seen the Spine image but had examined her back as I described before. I planned to do a spinal and the surgeon walked into the OR as I was sitting her up. He pulled up the image and waved me over. Basically, he said no way You get this, just put her to sleep. For a minute I almost listened to him but she was sitting up so I gave it a go. 30 seconds laterI laid her down and kicked back with my feet up the rest of the case. THATS A JOKE!
it took me a few minutes but I got CSF by going from right to left at an angle that I have never done before. I was glad to have the images but they were still only somewhat helpful.
So my question is, how many of you would have gone forward with a spinal in this pt and do you make a point to look at any images? What are the risks of blindly probing the spine in this condition? What link could there be btw scoliosis and MH? A quick google search only came up with one case of ptosis, scoliosis and MH. Maybe Blade can find something?
Click to expand...
I would have gone for the spinal. I can understand not wanting to do an epidural in her as I would assume that even if you did manage to not wet tap, there's a high chance it wouldn't get good coverage. Spinal catheter would have been an option for her if it's something the anesthesiologist and nurses/facility are comfortable with.
 
I would've given a solid college effort at a spinal (I tend to use the Touy as a guide in obese patients, ie, use the CSE kit) and if it's a no go, we go to sleep with prop/roc/ETT and TIVA. Hopefully last case of the day and have the machine flushing O2 through the circuit prior to the case.
 
Noyac said:
Well, I decided to proceed to the OR after the MH prep. I hadn’t seen the Spine image but had examined her back as I described before. I planned to do a spinal and the surgeon walked into the OR as I was sitting her up. He pulled up the image and waved me over. Basically, he said no way You get this, just put her to sleep. For a minute I almost listened to him but she was sitting up so I gave it a go. 30 seconds laterI laid her down and kicked back with my feet up the rest of the case. THATS A JOKE!
it took me a few minutes but I got CSF by going from right to left at an angle that I have never done before. I was glad to have the images but they were still only somewhat helpful.
So my question is, how many of you would have gone forward with a spinal in this pt and do you make a point to look at any images? What are the risks of blindly probing the spine in this condition? What link could there be btw scoliosis and MH? A quick google search only came up with one case of ptosis, scoliosis and MH. Maybe Blade can find something?
Click to expand...

like someone said above. the image helps. scan her ultrasound and go at low level. i wouldve attempted spinal even with that image
 
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okayplayer said:
Am I missing something? Why not just do a non triggering GA and move on with life?
Click to expand...
It's called "finesse" my freind.
And if the surgeon says i won't get the spinal, i'll do it even if it takes a 16ga tuohy to get it.
 
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okayplayer said:
Am I missing something? Why not just do a non triggering GA and move on with life?
Click to expand...
Nope. You are not missing anything. Other than this Pt was terrified of going to sleep and I told her I would do a spinal before I saw the image.
But none of that is really the point of the post.
 
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