My case for discussion

[IceDoc]

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I liked Noyac's post because it forces you to consider exactly why or why not you would do something. Here's a real case with similar circumstances.

55yo woman with metastatic breast cancer for a scheduled VATS pleurodesis for recurrent plural effusion. She is having her effusion tapped almost weekly with liters of fluid removed. Upon meeting her, she is tachypneic, using accessory muscles, and sats in the lo 90's. No breath sounds on the side of the effusion; the other side is normal. She mentions that she's really thirsty and she is urinating much less than usual. When she does, it is very dark.

So far so good, right? Let's continue. Labs from the day prior show a K+ of 5.6 and Na of 128. Repeat labs on day of surgery are the same. EKG coincidentally done within 30mins of the labs shows no abnormal T-waves, and is pretty much normal. Previous labs were hard to come by, but about 1 month ago her K+ was 4.3. She has no known renal disease, but is on potentially renal toxic chemotherapy. Her Cr is 1.1, baseline is unknown.

Sooooo...... Anyone bothered by the K+ of 5.6? What's your plan? Delay case and have her hyperkalemia of unknown origin medically managed first? (She can have the effusion simply tapped again in the meantime). Or charge ahead?

 

[militarymd]

Charge ahead...this is a simple case.

What are you concerned about?

 

[Planktonmd]

Hyponatremia + Hyperkalemia and dehydration:
Could she have adrenal insufficiency caused by steroid therapy or adrenal mets??
This is obviously a palliative procedure on a terminal patient, so I would treat empirically with corticosteroids, correct volume and proceed.

 

[Noyac]

She needs the effusion tapped first of all. You could do this with her awake or asleep but if you do it with her asleep you might as well proceed with the whole shebang.

 

[urge]

Pent, sux, tube. Agree with Plankton. Adrenal insufficiency fits the scenario. Doesn't necessarily mean she has it though.

 

[IceDoc]

Charge ahead...this is a simple case.

What are you concerned about?

Well yes, that's what I did. But don't you think an acute K+ of 5.6 is too high?
That's obviously a rhetorical question for mil, so let me ask it differently: In the absence of evidence of complications from hyperkalemia (i.e. EKG changes, cardiac arrest, etc...) what lab value of K+ would require management prior to going to the OR?


BTW, I saw no need to tap the effusion first since that's basically the first step of the VATS. What was cool to see was that when I stopped ventilating the bad lung, the EtCO2 went up like it's supposed to when you stop ventilating dead space.

 

[coprolalia]

Paraneoplastic syndrome. Nothing you can do about it. Your choice whether or not to do the anesthetic is not going to affect long-term outcome of this particular patient. You are in full palliation mode here.

Proceed.

-copro

 

[mille125]

Hyponatremia + Hyperkalemia and dehydration:
Could she have adrenal insufficiency caused by steroid therapy or adrenal mets??
This is obviously a palliative procedure on a terminal patient, so I would treat empirically with corticosteroids, correct volume and proceed.

this is a classic case of an addisonian patient....empirically treat with corticosteroids, correct volume, and proceed as plankton said

 

[cubs3canes]

this is a classic case of an addisonian patient....empirically treat with corticosteroids, correct volume, and proceed as plankton said

Dexmedetomidine, versed, lateral position, and local on the field.
o2 by face mask.

We do one of these awake per week. They are easy and the patients tolerate it well.

Cubs

 

[Planktonmd]

Dexmedetomidine, versed, lateral position, and local on the field.
o2 by face mask.

We do one of these awake per week. They are easy and the patients tolerate it well.

Cubs

Awake VATS?

 

[Noyac]

Dexmedetomidine, versed, lateral position, and local on the field.
o2 by face mask.

We do one of these awake per week. They are easy and the patients tolerate it well.

Cubs

What the F***?

Tell us (read: ME) how you do these.

 

[Planktonmd]

What the F***?

Tell us (read: ME) how you do these.

I have never seen an awake VATS so I am waiting for the details as well.

 

[cubs3canes]

I have never seen an awake VATS so I am waiting for the details as well.

I think I posted this before.

The Thoracic Surgeon was new to our facility about 1 year ago and he was used to doing the pleural effusion VATS (for pleurodesis and evacuation of fluid) awake.

We give the pt. midaz 2 mg in holding. Into the room. We load up the dexmed 1mcg/kg over 10 minutes. The patient positions themselves on the table to the correct side. We then run the dex at 4 mcg/kg/HOUR.

The surgeon then uses a good volume of local at the sites. All they are doing is draining fluid and then putting in talc or whatever they use these days. It should not take very long.

The surgeon also likes the NEGATIVE Pressure ventilation. He states it helps with the proper adhesion of the talc in the cavity.

Sometimes you need a little fentanyl (25mcg) before the infiltration of the local.

Try it on your sick VATS for pleurodesis, you will not go back.

Cubs

 

[Planktonmd]

I think I posted this before.

The Thoracic Surgeon was new to our facility about 1 year ago and he was used to doing the pleural effusion VATS (for pleurodesis and evacuation of fluid) awake.

We give the pt. midaz 2 mg in holding. Into the room. We load up the dexmed 1mcg/kg over 10 minutes. The patient positions themselves on the table to the correct side. We then run the dex at 4 mcg/kg/HOUR.

The surgeon then uses a good volume of local at the sites. All they are doing is draining fluid and then putting in talc or whatever they use these days. It should not take very long.

The surgeon also likes the NEGATIVE Pressure ventilation. He states it helps with the proper adhesion of the talc in the cavity.

Sometimes you need a little fentanyl (25mcg) before the infiltration of the local.

Try it on your sick VATS for pleurodesis, you will not go back.

Cubs

Can I borrow your surgeon sometime??
😀

 

[cubs3canes]

Can I borrow your surgeon sometime??
😀

He is pretty good and very fast.

However, the minimally invasive esophagectomies are still not very fun.

 

[Arch Guillotti]

We then run the dex at 4 mcg/kg/HOUR.

That's a pretty big dose of dex!

 

[Noyac]

So is he doing anything with the video?

What you described seems more like tapping a pleural effusion and then putting in some talc in the space. I did these on the floor in residency. Am I missing something?

 

[Jeff05]

her sats suck cause most of her bad side is a shunt. put in a double lumen or slip in a blocker - your oxygenation may actually improve.


you can absolutely do these cases with sedation and intercostal blocks. i just did an excision of a massive deep chest wall cyst with blocks and mac.

last week did VATS with blocks and mac.

 

[Noyac]

How long are these cases taking?

 

[cubs3canes]

How long are these cases taking?

one hour of operating time. Yes, these are quick.

The more that I think about it, the less I know why they do the video portion of these procedures. They look at the entire pleura, but most of the time the disease is very extensive.

The point is that this surgery does not require a double lumen tube or blocker. Unless they are resecting something, a VATS can be done awake.

Cubs

 

[ultm8frisbee]

Pent, sux, tube. Agree with Plankton. Adrenal insufficiency fits the scenario. Doesn't necessarily mean she has it though.

Wouldn't use sux with a K of of 5.6. I'd proceed, give 150mg of solumedrol. In the absence of EKG changes, I wouldn't be too concerned about the K. If she was having changes, I'd start insulin and glucose IV g++ in holding to drop the K. Prolly put in an artline after induction cause this gal is gonna have her blood gases checked regularly post-op. Our CTS guys expect one lung ventilation for all VATS cases.