Monday's case

[EV-Stentor]

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Yes it would be strange but the OP stated he was worried or concerned about that AS murmur....plus in my opinion the extra monitoing is really no big deal: risk benefit ratio easily favors putting in the A line...just don't call me if he develops a blue hand

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!

 

[militarymd]

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.

that's my point....What "great benefit" is there with regional over general?

That was true in the days of halothane and pancuronicum.....those "great benefits" do not exist anymore.

I'm so sick and tired of hearing ..."THe lungs are so bad that If we put him to sleep, he'll never come off the vent"....

That statement is simply NOT true ANYMORE.

The respiratory failure that occurs after patients undergoing up abdominal and thoracic procedures are the result of the anatomic changes that come from surgery.....

1) altered thoracic-abdominal anatomy
2) alveolar collapse from surgical manipulation and packing
3) decreased ability to participate in pulmonary toilet because of pain (post-op regional takes care of this )
4) fluid overload states from the stress response which alter pulmonary compliance
5) catabolic state which leads to weakened skeletal muscle from the stress response.

Modern anesthetics contribute little if at all to post op respiratory failure.

Sure...bad COPD May require an extra 30 minutes of emergence from anesthesia, but avoiding that is NOT a "great benefit".

 

[Planktonmd]

So you are saying: I can take a guy with advanced COPD, walking around with a CO2 of lets say 60, with lungs full of chronically infected secretions, who gets up in the morning and coughs for an hour before getting out of bed, I can take this guy to the OR, Induce GA using "modern" drugs, then intubate him and put him on mechanical ventilation for a couple of hours (lets say without surgery) and then take the tube out, and his respiratory physiology will be the same and he will be back to base line? You are also saying that the risk of keeping this guy intubated in the ICU in case I can't extubate him is not important and that he is not going to develop pneumonia and die?

 

[militarymd]

Colonization of secretions....and INFECTION are 2 distinct entities that many experienced clinicans will confuse.

Chronic bronchitis (a component of COPD) is not the same as infectious bronchitis, and ALL of us are colonized with bacteria at various times...that's why pulmonary procedures are NOT clean procedures.

And yes, GA for a guy like this is not as harmful as you think.....

Think about what we do when someone comes in with COPD exacerbations from various causes when the CO2 is 80.....we give them GA until they get better.

 

[Planktonmd]

Well,
MMD, I don't think we are going to reach an agreement, and since i like many of your other posts I am going to leave it at this. peace out.