Neuraxials for COPDers

[VentdependenT]

Does a neuraxial block decrease pulmonary complications for major surgeries? I think I read somewhere (Yao?) that it allows earlier reduction of atelectasis but that it really doesn't decrease the complication rate (overall morbidity and mortality).

Can ye confirm this?

We had a 300lber COPDer with an 80 pack yr hx, chronic SOB, a broken femur, DM, hemorrhagic anemia, tourettes, and positional GERD. Now the surgeons request general for an ORIF for the femur. I'm worried about prolonged post op extubation in the filthy ICU. She is a perfect set up for PE as well. She looked like a keg with legs. Oh yeah dob stress echo negative (although she PASSED out the first run through for unkown reasons...) and CXR shows no effusions with a slightly enlarged cardiac shadow.

Anyhoots I was thinking of neuraxial for this woman (assuming we could get it in) but I'd like to hear your opinions out the benifits vs risks for general vs a neuraxial in this case.

Venty.

Happy gobble day everyone

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[militarymd]

As the president of SARA,

I will voice that there is no definitive data on improvment in outcome at 30 days when comparing regional vs GA.

There is a lot of controversy and discussion on this topic, and my opinioin is that when there is a lot of controversy, it means that it really doesn't matter.

Things like beta-bockers and MI have no controversy because we have Class A data, so we know what we have to do.

The regional vs GA arguement persists because there is no data.

There is some data to support earlier extubation in certain patients undergoing certain types of surgery, but who really cares about a few hours of mechanical ventilation in the grand scheme of things.

I certainly don't.

As an intensivist, I prefer my COPDer's to come intubated so that the patients can be properly weaned to avoid reintubation at 6 hours post-op.

 

[davvid2700]

Does a neuraxial block decrease pulmonary complications for major surgeries? I think I read somewhere (Yao?) that it allows earlier reduction of atelectasis but that it really doesn't decrease the complication rate (overall morbidity and mortality).

Can ye confirm this?

We had a 300lber COPDer with an 80 pack yr hx, chronic SOB, a broken femur, DM, hemorrhagic anemia, tourettes, and positional GERD. Now the surgeons request general for an ORIF for the femur. I'm worried about prolonged post op extubation in the filthy ICU. She is a perfect set up for PE as well. She looked like a keg with legs. Oh yeah dob stress echo negative (although she PASSED out the first run through for unkown reasons...) and CXR shows no effusions with a slightly enlarged cardiac shadow.

Anyhoots I was thinking of neuraxial for this woman (assuming we could get it in) but I'd like to hear your opinions out the benifits vs risks for general vs a neuraxial in this case.

Venty.

Happy gobble day everyone

hey

im my opinion, any lower extremity procedure should be considered being done with a spinal or epidural. I love spinals and epidurals. And once again, if the patient has pulmonary issues (asthma, emphysema, etc) instrumenting the airway can be a catalyst to pulmonary complications.

That being said sometimes the patient has psych issues and a general anesthetic is truly the way to go, but it doesnt seem that was the case in your patient.

You are right to be thinking neuraxial. ANd if you were with me I would cheer you on as you popped aspinal in and they did the case. thats the way to go.

 

[bullard]

Re: extra hours of mechanical ventilation: wouldn't that extra time translate to lost $$? I guess you gotta pay the ICU nurse and the intensivists and RRTs whether they're intubated or not. But extra ventilation also means increased chance of VAP, no?

Re: beta blockers: did you happen to read this NEJM article a couple of months ago? What did you think?

Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery
Lindenauer P. K., Pekow P., Wang K., Mamidi D. K., Gutierrez B., Benjamin E. M.
N Engl J Med 2005; 353:349-361, Jul 28, 2005

As the president of SARA,

I will voice that there is no definitive data on improvment in outcome at 30 days when comparing regional vs GA.

There is a lot of controversy and discussion on this topic, and my opinioin is that when there is a lot of controversy, it means that it really doesn't matter.

Things like beta-bockers and MI have no controversy because we have Class A data, so we know what we have to do.

The regional vs GA arguement persists because there is no data.

There is some data to support earlier extubation in certain patients undergoing certain types of surgery, but who really cares about a few hours of mechanical ventilation in the grand scheme of things.

I certainly don't.

As an intensivist, I prefer my COPDer's to come intubated so that the patients can be properly weaned to avoid reintubation at 6 hours post-op.

 

[zippy2u]

Vent, yeah spinal would be nice choice. You being at an academic center with slow surgeons consider tetracaine 10 mgs. with 200 mikes epi and 25 mikes fentanyl for spinal. Tell surgeons to get in there and "git her done" and not monkey around. Regards,--- Zip

 

[MAC10]

Along the same lines would you use an LMA on someone with severe asthma or copd? Ive read its less stimulating to the airway but ive been told not to use one once cause the pt had asthma.

Sorry to hijack your thread Vent. Carry on

 

[VentdependenT]

Not a hijack my friend. Just happy to see some healthy discussion.

As usual there is no definitive answer. If she where to be intubated it would have to be FOI. And an awake one at that. She would be a class IV with no neck and all fat....so it would be nice to avoid having to put someone through that.

I'll find out who did the case and relay the info to yall.

Tanks for the spinal info zipster.

 

[davvid2700]

Not a hijack my friend. Just happy to see some healthy discussion.

As usual there is no definitive answer. If she where to be intubated it would have to be FOI. And an awake one at that. She would be a class IV with no neck and all fat....so it would be nice to avoid having to put someone through that.

I'll find out who did the case and relay the info to yall.

Tanks for the spinal info zipster.

Good point about the difficult airway. A spinal would definitely avoid the airway. so in this situation take your time do it well the first time..

BUt........... what would you do if it went high? now you have a difficult airway and someone crapping out on you.. now you have to deal with the difficult airway under semi urgent conditions.. Or even better.. for some reason the spinal doesnt work (unlikely) or doesnt last long enough.. How would you induce anesthesia in a patient who has a class 4 airway(known difficult airway). No right answer really Just think about all these things pre op and be able to come up with a plan to deal with it.. This is clearly a board scenario.. probable every single year..

 

[jetproppilot]

As the president of SARA,

There is some data to support earlier extubation in certain patients undergoing certain types of surgery, but who really cares about a few hours of mechanical ventilation in the grand scheme of things.


As an intensivist, I prefer my COPDer's to come intubated so that the patients can be properly weaned to avoid reintubation at 6 hours post-op.

HAHAHAHAHAHHAHAHAHAH

SARA. You crack me up. I think I dated her once.

One could argue theres no such thing as weaning.

A patient's pulmonary status is either ready or not for extubation.

A "weaning trial" is something internal medicine dudes perpetuate so they can justify rounding. And have something to talk about on rounds. And make their notes longer.

 

[davvid2700]

One could argue theres no such thing as weaning.

A patient's pulmonary status is either ready or not for extubation.

A .

very true... very true// ICU book..

they talk about t peice trials and simv trials which one is longer which one is better but the point is.. IF the lungs are ready the lungs are ready and no wearning trial will miraculaously make the lungs better.. Time will, antibiotics will, permissive hypercapnia will but the weaning method doesnt matter

 

[militarymd]

Re: extra hours of mechanical ventilation: wouldn't that extra time translate to lost $$? I guess you gotta pay the ICU nurse and the intensivists and RRTs whether they're intubated or not. But extra ventilation also means increased chance of VAP, no?

Re: beta blockers: did you happen to read this NEJM article a couple of months ago? What did you think?

Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery
Lindenauer P. K., Pekow P., Wang K., Mamidi D. K., Gutierrez B., Benjamin E. M.
N Engl J Med 2005; 353:349-361, Jul 28, 2005

The article was OK....with reference to Polderman...which showed the risk reduction effects in a prospective fashion.

This article was similar in methodology to Connors on the Swan in 1996...good, but retrospective...although it did support data that is already done in a prospective manner.

 

[militarymd]

HAHAHAHAHAHHAHAHAHAH

SARA. You crack me up. I think I dated her once.

One could argue theres no such thing as weaning.

A patient's pulmonary status is either ready or not for extubation.

A "weaning trial" is something internal medicine dudes perpetuate so they can justify rounding. And have something to talk about on rounds. And make their notes longer.

"weaning trial" is just a term used to describe the process by which you find out whether the patient is ready for extubation or not.

 

[VentdependenT]

In the unit we would throw em on pressure support with peep and let em duke it out with the vent for a half an hour. If the frequency over tidal volume ration was less than 100 and they were stable (no neurologic depression as well) that was a successful wean.

For neuropathic pt's we'd toss a nif in there I think.

Of course when the pt nods yes to the question "do you want the tube out" thats a good indicator.

We never used SIMV at masonic MICU. If they needed the vent we would just sedate them and throw on AC. No need to waste that WOB effort between assisted vents with pressure support. Wake em up for a wean once the abg's and vitals looked wean worthy.

I dunno where this thing went but I like vents.

 

[jetproppilot]

"weaning trial" is just a term used to describe the process by which you find out whether the patient is ready for extubation or not.

Not to medicine dudes...

To them, it is a laborious, time consuming process that needlessly eats up alot of ICU resources.

This is only one example of many.

Thats where intensivists come into play...and why I think anesthesiologist intensivists make better intensivists than pulmonary intensivists.

 

[militarymd]

Not to medicine dudes...

To them, it is a laborious, time consuming process that needlessly eats up alot of ICU resources.

This is only one example of many.

Thats where intensivists come into play...and why I think anesthesiologist intensivists make better intensivists than pulmonary intensivists.

You've met bad ones then.

 

[AJM]

...and why I think anesthesiologist intensivists make better intensivists than pulmonary intensivists.

Oh no you DI'INT just say dat....


Yeah, you have met bad ones...

 

[augmel]

I can't comment on who's better since I've never worked with Anesthesiology intensivists, but the pulm/cc folks I know didn't waste time "weaning." Is the tobin good? Are they an airway disaster? Get it out. And if you don't have to reintubate every once in a while, then you are leaving people on too long. VAP is bad. VentD, I too like vents.

 

[jetproppilot]

Along the same lines would you use an LMA on someone with severe asthma or copd? Ive read its less stimulating to the airway but ive been told not to use one once cause the pt had asthma.

Sorry to hijack your thread Vent. Carry on

Wouldnt hesitate to use one.

 

[Noyac]

Good point about the difficult airway. A spinal would definitely avoid the airway. so in this situation take your time do it well the first time..

BUt........... what would you do if it went high? now you have a difficult airway and someone crapping out on you.. now you have to deal with the difficult airway under semi urgent conditions.. Or even better.. for some reason the spinal doesnt work (unlikely) or doesnt last long enough.. How would you induce anesthesia in a patient who has a class 4 airway(known difficult airway). No right answer really Just think about all these things pre op and be able to come up with a plan to deal with it.. This is clearly a board scenario.. probable every single year..

When is the last time any of you have seen a high spine?

 

[Noyac]

Wouldnt hesitate to use one.

Ditto!

 

[beezar]

When is the last time any of you have seen a high spine?

But for those of you taking your oral boards, if you say you choose the spinal route, I guarantee the next thing the examiner says is that it becomes a high spinal in a morbidly obese pt with a crappy airway exam and quite possibly difficult intubation... now what?

So even though the oral boards are not based in reality, probably pick the "secure the airway and do a GA" route on the boards.

 

[davvid2700]

But for those of you taking your oral boards, if you say you choose the spinal route, I guarantee the next thing the examiner says is that it becomes a high spinal in a morbidly obese pt with a crappy airway exam and quite possibly difficult intubation... now what?

So even though the oral boards are not based in reality, probably pick the "secure the airway and do a GA" route on the boards.

that was my point in my post earlier in the thread. there are two schools of thought on "regional anesthesia for the difficult airway"

1) secure the airway first...
2) regional to avoid the airway

and if you pick number 2 you bet your ass the examiner will make your block fail..