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Let’s do another case

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?
 

jeesapeesa

anesthesiologist southern california
Apr 1, 2007
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  1. Attending Physician
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?

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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narcotics999

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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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deleted162650

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?

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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Nov 24, 2007
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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.
 
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Noyac

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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.
You know me better than that. Hang tight bitch.
 
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Noyac

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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?
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?
 

Noyac

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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.
I reviewed the case a couple days after it happened last year. I remember it well. It was real.
 

coffeebythelake

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Apr 9, 2006
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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?

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.
 

coffeebythelake

Supreme Commander Anesthesiologist
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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?

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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Hork Bajir

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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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Newtwo

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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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DrOwnage

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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).
 

Noyac

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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
Oh lord. I wish for the sake of this post it was that interesting.
 
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deleted59964

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.
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
 
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cchoukal

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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

If there's a better word for a case gone sideways than "fandango," I don't wanna hear about it.
 
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deleted162650

Does it concern anyone that she has returned again a year latter for the same issue? Issue being the periectal abscess, not the MH.

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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Noyac

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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.
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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Noyac

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@Noyac we choose to bring her into the OR and push prop... What happens next? Curious where this is going
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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DocVapor

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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?
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.
 

Twiggidy

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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.
 

anbuitachi

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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?

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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Noyac

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Am I missing something? Why not just do a non triggering GA and move on with life?
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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