Monday's case

[dhb]

70 y/o male with COPD Gold IV: FEV 27% of predicted value and CO diffusion +- 30% too. 94% O2 Sat on home O2 2l/min
No other medical problems heart echo from last year shows a normal EF and a 1/4 aortic insufficiency.
Listed for Chole with umbilical hernia repair (don't know at this point if surgeons plans on doing a laparoscopy but i guess not considering the hernia)
I see him at 3:30 on friday on auscultation i hear a 2-3/6 holosystolic murmur which sounded more like Ao stenosis to me no h/o symptoms though.
Has been doing intense physical rehab for 3 weeks which has improved his walking distance w/o dyspnea.

So would you repeat echo?
What's your plan?

 

[militarymd]

If I had a U/S machine available...and I do. I use a surface probe....apical view...and fire off a CW across the Aortic valve...

See what the velocity is...anything greater than 2 meter/ second...I will put in an A-line for induction....

Otherwise NIBP for case.

If no machine available...assume greater than 2 meter/second velocity..and proceed.

 

[dhb]

epidural or GA?

 

[militarymd]

regional for a Lap Chole in some one with bad lungs?

 

[VolatileAgent]

this seems like a pretty routine-type case we see almost on a daily basis here. sadly, more and more patients are presenting like this and this type of patient is exactly why you need an anesthesiologist overseeing the care throughout the case.

if he'd come to our clinic, he would've gotten another pre-op outpatient echo based on your clinical findings. sounds like he didn't here. if the echo showed significant, or even critical, AS, then the a-line before induction, using titrated etomidate for induction.

he would also, assuming it's an open (which is what it sounds like), definitely get a thoracic epidural here mostly for post-op pain control, but this would help the intra-op too. naturally, you'd have to be careful with knocking out the sympathetics, but this is manageable if you're paying attention.

at induction, i'd squirt an LTA in to boot before the tube. i'd probably tank him up in the holding area as well because more often than not, these patients run a little drier than most anticipate. with the epidural, i'd run a light GA and top-up as needed during the case.

literally have done dozens of such cases in similar patients (some sicker) without problems. it's all about proper planning, as everyone should agree. trusting he didn't have a carotid thrill, too. the real caveat though is that a II-III/VI sounds fairly significant and, if new, should really be properly evaluated before taking the guy to the OR.

of course, if you're MMD, you take everyone to the OR no matter what and deal with the problems if/when they arise. riskier? clearly.

me? i operate under the PPPPPP credo. you're either a trouble-shooter type technician, or your a flea. i'm more the latter.

 

[dhb]

regional for a Lap Chole in some one with bad lungs?

Well he's getting an epidural anyway so why not just leave it at that (and be prepared to intubate if needed)

What i really want to know is how easy will it be to get him off the vent

 

[militarymd]

this seems like a pretty routine-type case we see almost on a daily basis here. sadly, more and more patients are presenting like this and this type of patient is exactly why you need an anesthesiologist overseeing the care throughout the case.

if he'd come to our clinic, he would've gotten another pre-op outpatient echo based on your clinical findings. sounds like he didn't here. if the echo showed significant, or even critical, AS, then the a-line before induction, using titrated etomidate for induction.

he would also, assuming it's an open (which is what it sounds like), definitely get a thoracic epidural here mostly for post-op pain control, but this would help the intra-op too. naturally, you'd have to be careful with knocking out the sympathetics, but this is manageable if you're paying attention.

at induction, i'd squirt an LTA in to boot before the tube. i'd probably tank him up in the holding area as well because more often than not, these patients run a little drier than most anticipate. with the epidural, i'd run a light GA and top-up as needed during the case.

literally have done dozens of such cases in similar patients (some sicker) without problems. it's all about proper planning, as everyone should agree. trusting he didn't have a carotid thrill, too. the real caveat though is that a II-III/VI sounds fairly significant and, if new, should really be properly evaluated before taking the guy to the OR.

of course, if you're MMD, you take everyone to the OR no matter what and deal with the problems if/when they arise. riskier? clearly.

me? i operate under the PPPPPP credo. you're either a trouble-shooter type technician, or your a flea. i'm more the latter.

That's why I'm a physician....I can do my own echo....while you need to ask someone else to do it......

Sort of like a CRNA asking a MD for a consult.....(no offense to CRNA's)



AND no evidence that I'm riskier......but the fact is your approach wastes time and money.....which ultimately leads to economic failure.....which then leads to poorer patient care because it won't be the best and brightest going into anesthesia anymore.

 

[VolatileAgent]

That's why I'm a physician....I can do my own echo....while you need to ask someone else to do it......

Sort of like a CRNA asking a MD for a consult.....(no offense to CRNA's)



AND no evidence that I'm riskier......but the fact is your approach wastes time and money.....which ultimately leads to economic failure.....which then leads to poorer patient care because it won't be the best and brightest going into anesthesia anymore.

you're funny.

such an angry, angry man. you must be really insecure in the real world.

 

[SexPanther]

you're funny.

such an angry, angry man. you must be really insecure in the real world.

Could we refrain from insults on this thread fellas? As a student and soon to be resident, I'm interested in hearing the different perspectives but I'm tired of threads degenerating to a pissing match (usually involving VA and mil).

 

[VentdependenT]

G'head and throw an aline in if you want. Takes little time and if you feel that beat to beat would be helpful in this guy go for it. However its his LUNGS that are toast and an aline wont help.

Laproscopic? Straight GA with ETT. Let patient know that he may have to spend some time on the vent POST OP.

OPEN: Thoracic epidural for sure for post op pain. This guy is a perfect set up for post op respiratory failure with that high abdominal incision. You may choose either to LMA or ETT this guy during the case for POSITIVE PRESSURE VENTILATION which he SURELY WILL NEED with sedation.

I can only hope to know my TEE's someday. They are hard as hell man. Maybe next year.

 

[militarymd]

Could we refrain from insults on this thread fellas? As a student and soon to be resident, I'm interested in hearing the different perspectives but I'm tired of threads degenerating to a pissing match (usually involving VA and mil).

Tell the fat, balding, big eared, doubled chinned guy to stop starting the insults and I won't have to respond in kind.

 

[militarymd]

.....

I can only hope to know my TEE's someday. They are hard as hell man. Maybe next year.

TEE is not helpful here....you want to image the valve before anestheitzing the patient....that's why I would use a surface probe.

 

[Planktonmd]

The key word is "assymptomatic".
severe aortic stenosis gives you symptoms.
The guy is not complaining of Angina or Syncope and his excercise tolerance is acceptable and improving.
If they choose to do an open procedure I would do a thoracic epidural and try to achieve a segmental block with minimal sedation "keep him awake".
I have done it many times on patients with very bad lungs and never had to intubate anyone. If the epidural is patchy you can add some intercostal blocks.
If it is going to be a Laparoscopy which I think is better for this patient (in the right hands), Just do a good general anesthetic, use PEEP intra-op, Intercostal blocks might still be a good idea for post op pain or even a thoracic epidural but that doesn't mean a straight GA wont do it.
You will most likely be able to extubate him without problems.
I would extubate this guy deep if possible.
The A line is purely optional.

 

[dhb]

If they choose to do an open procedure I would do a thoracic epidural and try to achieve a segmental block with minimal sedation "keep him awake".

That was what i am leaning towards.

Just do a good general anesthetic, use PEEP intra-op

Do you worry about using PEEP with emphysema?

You will most likely be able to extubate him without problems.
I would extubate this guy deep if possible.

I don't have experience of weaning patients with COPD from the vent what could be the problems?
My take is that by improving his ventilation and correcting his hypercapnia you decrease his ventilatory drive should you allow a degree of hypercapnia intra-op?

 

[militarymd]

Why is this going to be a OPEN procedure?

Am I missing something?

Lap Chole...Lap hernia repair....

or

Lap Chole....tiny incision for hernia repair.

 

[Planktonmd]

Why is this going to be a OPEN procedure?

Am I missing something?

Lap Chole...Lap hernia repair....

or

Lap Chole....tiny incision for hernia repair.

I agree, I don't see a reason to do an open procedure, but I am just a private practice guy, what would I know

dhb:
To extubate the guy let the CO2 rise gradually at the end, and it should not be difficult with all the CO2 they are going to inflate the abdomen with.
PEEP is not a problem in Emphysema, unless they have a history of frequent spontaneous pneumothorax, and that would be a completely different group of patients and circumstanses. Just don't go crazy with PEEP.
There is a good amount of art involved in extubating a patient with bad lungs, and you will find out that different people do it differently, and there will be times when you can't do it and you have to be able to recognize that and accept it.

 

[Noyac]

GA without an epidural or a-line. No way this should be open unless the surgeon gets uncontrollable bleeding during the case. I have only seen this twice in 10 years and both were in residency.

Vent, you mentioned LMA in an open case with an epidural. I would be reluctant to proceed this way. I want control of the respiratory mechanics but it is possible. I find that pts with bad lungs usually do fine even with GETA. Pain is another issue of course. If they need to open then put in a epidural post-op. Even asleep if necessary just consent b/4 the case.

 

[IceDoc]

Well he's getting an epidural anyway so why not just leave it at that (and be prepared to intubate if needed)

What i really want to know is how easy will it be to get him off the vent

So, if you're going to put in an epidural, does that change your desire for knowing what his AV looks like?

 

[dhb]

Well if it's open then you can go with epidural only technique which wouldn't work with the lap...

 

[militarymd]

Well if it's open then you can go with epidural only technique which wouldn't work with the lap...

Epidural anesthesia for an open chole on someone with bad lungs?????

 

[Noyac]

Epidural anesthesia for an open chole on someone with bad lungs?????

YOu know it can be done. Why the confusion.

 

[Planktonmd]

Epidural anesthesia for an open chole on someone with bad lungs?????

Absolutely.

 

[militarymd]

Just seems like a bad idea......meaning....instead of intubating and controlling the airway from the begininng...

you wait to do it some time in the middle of the case when you got other stuff going on.

 

[Noyac]

Just seems like a bad idea......meaning....instead of intubating and controlling the airway from the begininng...

you wait to do it some time in the middle of the case when you got other stuff going on.

Coming from the President of SARA, expect nothing different. But personally, I have no problem with it and would really need to have a good reason not to place one.

 

[Planktonmd]

Just seems like a bad idea......meaning....instead of intubating and controlling the airway from the begininng...

you wait to do it some time in the middle of the case when you got other stuff going on.

This is the worst case scenario, and sure it can happen. but if you know what you are doing and dose you epidural carefully, this can be a very elegant anesthetic and the patient will avoid intubation and mechanical ventilation, he will also have great post op analgesia.
Just remember that most of these patients depend on their diaphragm for breathing, so don't let your epidural get cervical

 

[militarymd]

This is the worst case scenario, and sure it can happen. but if you know what you are doing and dose you epidural carefully, this can be a very elegant anesthetic and the patient will avoid intubation and mechanical ventilation, he will also have great post op analgesia.
Just remember that most of these patients depend on their diaphragm for breathing, so don't let your epidural get cervical

Is that right?

COPD'er's (with their flattened diaphragms on CXR's) depend on their diaphragms to breath.

I would have never guessed.

 

[Noyac]

Accessory muscles!

 

[Planktonmd]

Is that right?

COPD'er's (with their flattened diaphragms on CXR's) depend on their diaphragms to breath.

I would have never guessed.

Flattened diaphragms on XR does not mean that they are not using their diaphragms to breath.
Also distended chests make your intercostal muscles pretty useless.
I am speaking from personal experience doing these cases under epidural anesthesia that's all.
I wish you limit srcasm and remember I am not one of these residents you are trying to impress.

 

[militarymd]

Flattened diaphragms on XR does not mean that they are not using their diaphragms to breath.
Also distended chests make your intercostal muscles pretty useless.
I am speaking from personal experience doing these cases under epidural anesthesia that's all.
I wish you limit srcasm and remember I am not one of these residents you are trying to impress.

I'm not trying to impress you AND I'm not being sarcastic.

Would you mind explaining to me how a flat diaphragm move air into and out of the thoracic cavity?

especially after a subcostal incision for the cholecystectomy.

 

[Planktonmd]

I'm not trying to impress you AND I'm not being sarcastic.

Would you mind explaining to me how a flat diaphragm move air into and out of the thoracic cavity?

especially after a subcostal incision for the cholecystectomy.

Sure, I have no problem explaining to you what I said :
First, I did not say that upper abdominal surgery is a good thing for diaphragmatic movement, It will interfere with it as you know, what I said was "Don't get a cervical level block because you will paralyse the diaphragm and cause acute respiratory faliure in a patient with chronic respiratory faliure" Are we ok so far?
This is why you are reluctant doing an interscalene block in a patient with chronic respiratory faliure. You don't want to take away their diaphragmatic component of respiratory work. ok?
In healthy people the diaphragm does 60 to 70 % of the inspiratory work and the rest is done by the external intercostal muscles and the scalene muscles.
The Sternomastiod is recruited last.
In chronic respiratory faliure with emphysema the thoracic cavity distends by the emphysamtous lungs, and that pushes the diaphragms down and also stretches the intercostal muscles, so both components of inspiration are affected, and possibly the percentage of diaphragmatic participation is altered, but the diaphragm is still mobile and still playing a fundamental role in inspiration.
So although the diaphragm appears flat on X ray, it's still mobile and breathing and if you paralyse it you will put the patient in acute respiratory faliure, that was my point.
Now let's say you do a thoracic epidural and proceed with RUQ open surgery, the right diaphragm might be limited by the surgical instruments but it can still move, and if you titrate your epidural gently and gradually hopefully you won't take away all the work of the intercostal muscles, add to that the abscence of post op pain and you might be able to see why an epidural could be a good anesthetic in this setting.
Now I am in no way saying that this is the best way to do this surgery, and I still think that laparoscopy is the way to go, but it can be done.
Did I explain enough?

 

[Planktonmd]

Sure, I have no problem explaining to you what I said :
First, I did not say that upper abdominal surgery is a good thing for diaphragmatic movement, It will interfere with it as you know, what I said was "Don't get a cervical level block because you will paralyse the diaphragm and cause acute respiratory faliure in a patient with chronic respiratory faliure" Are we ok so far?
This is why you are reluctant doing an interscalene block in a patient with chronic respiratory faliure. You don't want to take away their diaphragmatic component of respiratory work. ok?
In healthy people the diaphragm does 60 to 70 % of the inspiratory work and the rest is done by the external intercostal muscles and the scalene muscles.
The Sternomastiod is recruited last.
In chronic respiratory faliure with emphysema the thoracic cavity distends by the emphysamtous lungs, and that pushes the diaphragms down and also stretches the intercostal muscles, so both components of inspiration are affected, and possibly the percentage of diaphragmatic participation is altered, but the diaphragm is still mobile and still playing a fundamental role in inspiration.
So although the diaphragm appears flat on X ray, it's still mobile and breathing and if you paralyse it you will put the patient in acute respiratory faliure, that was my point.
Now let's say you do a thoracic epidural and proceed with RUQ open surgery, the right diaphragm might be limited by the surgical instruments but it can still move, and if you titrate your epidural gently and gradually hopefully you won't take away all the work of the intercostal muscles, add to that the abscence of post op pain and you might be able to see why an epidural could be a good anesthetic in this setting.
Now I am in no way saying that this is the best way to do this surgery, and I still think that laparoscopy is the way to go, but it can be done.
Did I explain enough?

I know I spelled failure wrong several times, well at least i did not say "nucular"

 

[militarymd]

quote from Dr. J. Steadmen, "It's not going to work. I've done that experiment before."

 

[Planktonmd]

quote from Dr. J. Steadmen, "It's not going to work. I've done that experiment before."

Wow that was fast.
I can't argue with Dr. Steadman you know that
But I did the experiment several times and it worked

Please give her my best wishes.

 

[fakin' the funk]

Tell the fat, balding, big eared, doubled chinned guy to stop starting the insults and I won't have to respond in kind.

Seriously? "He started it"??? Seriously?

 

[dhb]

quote from Dr. J. Steadmen, "It's not going to work. I've done that experiment before."

well others have too

and

anyways case when fine with epidural + GA

 

[Arch Guillotti]

well others have too

and

anyways case when fine with epidural + GA

yeah but those those studies don't mean anything since MMD says it isn't possible and his opinion is obviously the only one that matters

 

[militarymd]

Here is a concept worth reading about:

Number Needed to Treat to:

1) cause harm
2) observe a benefit

As applied here.

 

[Noyac]

Here is a concept worth reading about:

Number Needed to Treat to:

1) cause harm
2) observe a benefit

As applied here.

Dude, you do it your way and rest of us can do it our way. Neither is wrong until the pt does badly. THen we can argue all over again. Deal?

 

[militarymd]

Dude, you do it your way and rest of us can do it our way. Neither is wrong until the pt does badly. THen we can argue all over again. Deal?

That's the problem with our specialty.....anyone can do anything (including non-physicians)....and nothing is "wrong"......

 

[Noyac]

That's the problem with our specialty.....anyone can do anything (including non-physicians)....and nothing is "wrong"......

Problem? You know that anesthesia is an art of sorts. I can do any case the same way you do it and I'm sure you can do the same. The difference is that I have better results when I do it my way and you have better results your way. I don't see a problem here. Your right if you are saying that "nothing is wrong" even though one is obviously better for the pt, but this is rarely the case. We all know this and we all believe that we are practicing the best way. I may be different in that I don't necessarily believe there is a best way at all times. I find it to be provider dependent. Therefore, the Art.

 

[dhb]

That's the problem with our specialty.....anyone can do anything (including non-physicians)....and nothing is "wrong"......

BTW you still haven't told us what you would have done... and why you think your method is superior...

 

[militarymd]

BTW you still haven't told us what you would have done... and why you think your method is superior...

I would put him to sleep.

How do you define "superior"?

post op MI.... Post op DVT....efficiency of time into room to cut ...and out????

As Noyac pointed out ...you can do it many different ways.

My way works EVERY time. I can COUNT on it working EVERY time.

Patient WILL make it through surgery on the technique....no change in technique needed.

All the pulmonary mechanical changes that our anesthesia books talk about are based on agents that we don't use anymore....pancuronium, halothane, enflurane.....stuff like that....doesn't apply anymore.

 

[dhb]

That's the problem with our specialty.....anyone can do anything (including non-physicians)....and nothing is "wrong"......

I thought that you were inferring that there was a "better" method

My way works EVERY time. I can COUNT on it working EVERY time.

If you hit them hard enough in the head i'm sure it does
So epidural + ga or strait ga narc for post-po?

 

[militarymd]

I thought that you were inferring that there was a "better" method



If you hit them hard enough in the head i'm sure it does
So epidural + ga or strait ga narc for post-po?

If there is a high likelihood of opening....epidural for POST-OP pain...otherwise straight ga.

Seems silly to pick a technique (straight regional) where you will have a high failure rate.....and for what benefit?

 

[Noyac]

If there is a high likelihood of opening....epidural for POST-OP pain...otherwise straight ga.

Seems silly to pick a technique (straight regional) where you will have a high failure rate.....and for what benefit?

Yes, I agree that if this is not an open case then there is no need for an epidural, IMHO.

Off the topic a bit here, but MIl, a nurse in my OR was looking over my shoulder and began to laugh at your avatar. I asked her what was so funny and she said you have a Donor sign under your avatar's motorcycle picture.

 

[EV-Stentor]

Hey Vent the dude has III/VI holosystolic murmur so he may very well have critical Aortic Stenosis...A line is imperative IMHO since when such pts code they are virtually unresuscitable..no CPP...lungs are NOT the only problem here bro. Also post op Pain management can be achieved easily with intra-lesional catheter and bupivacaine..Q Pump...Thoracic epidural is alright as well but i reserve mine for thoracotomies. Peace

G'head and throw an aline in if you want. Takes little time and if you feel that beat to beat would be helpful in this guy go for it. However its his LUNGS that are toast and an aline wont help.

Laproscopic? Straight GA with ETT. Let patient know that he may have to spend some time on the vent POST OP.

OPEN: Thoracic epidural for sure for post op pain. This guy is a perfect set up for post op respiratory failure with that high abdominal incision. You may choose either to LMA or ETT this guy during the case for POSITIVE PRESSURE VENTILATION which he SURELY WILL NEED with sedation.

I can only hope to know my TEE's someday. They are hard as hell man. Maybe next year.

 

[militarymd]

Yes, I agree that if this is not an open case then there is no need for an epidural, IMHO.

Off the topic a bit here, but MIl, a nurse in my OR was looking over my shoulder and began to laugh at your avatar. I asked her what was so funny and she said you have a Donor sign under your avatar's motorcycle picture.

I hadn't noticed....that is pretty funny

 

[Planktonmd]

Seems silly to pick a technique (straight regional) where you will have a high failure rate.....and for what benefit?

The big benefit is avoiding intubation in a patient with advanced lung disease.
That is a great benefit in my opinion, and if you haven't seen it before, that doesn't mean it can not be done!
Anyway, I feel that I am beating a dead horse here.

 

[Planktonmd]

Hey Vent the dude has III/VI holosystolic murmur so he may very well have critical Aortic Stenosis...A line is imperative IMHO since when such pts code they are virtually unresuscitable..no CPP...lungs are NOT the only problem here bro. Also post op Pain management can be achieved easily with intra-lesional catheter and bupivacaine..Q Pump...Thoracic epidural is alright as well but i reserve mine for thoracotomies. Peace

I thought the guy had a year old Echo that did not show Aortic stenosis!
It would be really strange if he went from no aortic stenosis to severe aortic stenosis in one year!

 

[EV-Stentor]

Hey Mil this in NOT a problem at all.....many ways to skin the cat as you very well know

That's the problem with our specialty.....anyone can do anything (including non-physicians)....and nothing is "wrong"......