New attending... should I have cancelled this case?

[Intrathecal]

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On call at this tiny community hospital this week where ortho likes to post cases AFTER his office hours. I have no CRNA help after 4pm. Today posted a hip ORIF on a SICK dude for 3:45pm... I really, really wanted to say no go, but who am I to cancel an ortho dude's case who has been there for 10+ years? Anyway this patient's problems are as listed:

PMHx: 65yo AAM
1. ESRD, HD M/W/F through fistula in left groin
2. HTN
3. CHF, Echo from last week shows EF 30-35% but no significant valvular abnl
4. ?Hypercoagulable state, however patient has abnl coags with INR of 1.3, PTT in 40s don't remember exact number
5. OSA with moderate pulm HTN
6. Multiple failed AV fistulas in both upper extremities

He comes to my OR with a teeny 20Ga IV that BARELY runs.
Surgeon wanted me to place a spinal but I said no to that because of his questionable coagulation state, plus difficulty in controlling BP with large sympathectomy with spinal, and he has been on/off lovenox and heparin for HD.

Labs are as follows: Hgb 12.1, plt 124, K+ 3.5, CREATININE 9!, INR 1.3, PTT 40s

So first question is, would you have cancelled the case based on the above data?

Now, allow me to add that my hospital has NO etomidate, and NO cisatracurium. WHat do you think now?

Anyway, I talked to the surgeon voicing my concern that the patient is an ASA 4.5 and he will likely go to the ICU after this case, IF he makes it out of the OR, he says "I get it" in a way to say he doesn't give a **** and wants to proceed. Also says that if dude doesn't have this done he won't make it out of the hospital.

So the circ nurses wheel this dude into the OR. I look at both of his arms and look like there are pythons crawling up both arms from his failed fistulas.

I placed an a-line in his right radial artery with ease.

Induction with 4mg midaz, 200mcg fentanyl, and 30mg roc. BP did not budge and I waited a couple minutes and attempted DL. Patient started wiggling, so I stopped and gave 30mg of propofol. Mask ventilated for another minute or so, BP drops slightly to 120s/50s.

I DVL again and get a grade 3 view. Of course he was in a traction bed where I am leaning horizontally across the head of the bed to intubate. I was able to sneak an 8.0 ETT around the epiglottis, wasn't 100% sure I was in, but saw mist in tube and hook up to circuit and bam +ETCO2!

After that the patient was relatively stable, I had to give some neo and ephedrine at the beginning when he wasn't being stimulated, and I had to keep him on 1% sevo +45% NO2 to keep his BP from falling. I also placed a fresh 18 Ga PIV

So surgery was uneventful UNTIL the end after dressing is placed. 4 twitches, reversed with 2mg neostigmine and 0.4 glyco. 1mg morphine (no hydromorphone at this hospital). Right after the dsg goes on and as the circulator was moving the lower extremity onto the bed, BP falls precipitously from 108/50, to 75/40, then 65/30, 50/25... and lower..., all within about one minutes, HR starts to fall as well...

I gave more ephedrine to no avail. At this point I alert everyone that the patient is not doing well and to grab the code cart. I break open the epi vial and gave a quarter of a syringe, and bam BP and HR came back up. I was about 10 seconds away from thumping on the dude's chest.

At this point we also lost out Pulse Ox reading, probably due to poor perfusion and maybe hypoxemia as well.

I attempted to start a central line in the R IJ, but I knew it would be difficult because there is a scar there from a previous perma-cath. I was able to hit the IJ but could not thread the wire. At this point I noticed a hematoma developing, which made me glad I didn't attempt a spinal. So I aborted the IJ attempt.

At this point the patient was more stable with BP of 134/78, sent ABG and got: 7.40/30/386/19 on FiO2 100%, so I decided to take him to the ICU tubed with plenty of code drugs with me.

I think he most likely had a fat emboli that caused this event. Plus this dude had no reserve whatsoever, with 3 failing organs, so even with small emboli he could not compensate well. Checked on him again before leaving the hospital (I had another emergent ERCP to do on a demented 81 yo after this disaster case) and he was stable with MAPs hanging out in the 70s on propofol drip.

Anyway, I want to hear opinion from some PP veterans... would you have cancelled the case, given the circumstances?

Thanks for reading the long post BTW, now I am going to go to bed and pass out. Oh I am starting to miss the good ole residency days. 😴

 

[jetproppilot]

There is no right answer, but I'll give you my opinion.

That teeny tiny 20" IV is plenty to get you through if the ortho dude is deft. After he's asleep, if you're uncomfortable, stick away....look at the EJs...

Your comment about your hospital not having etomidate/cisatracurium.....etomidate, because of anesthesia myth propegated by our residency programs, somehow has garnered superiority over propofol when hemodynamic instability is suspected to occur with induction...

...even though etomidate has been linked to mortality increase....

so propofol-or-some-other-induction-agent will do just fine....actually a better choice.......just in smaller doses.

You couldve given propofol right off the bat which wouldve avoided your struggle.....30mg roc? Thats great. Turn your O2 up all the way, turn your sevo up to about 4, and mask away for a cuppla minutes......sub-intubating doses of roc work well....ya just haffta wait a little longer and get a little gas on board while masking, then intubating conditions are OK.

As for your lack of cisatracurium....use vecuronium or rocuronium (like you did) whose primary route of elimination is hepatic glucuronidation....or use no neuromuscular blocker for maintenance (you can use sux for induction on a dude like this, btw).....just turn your sevo a little higher....

As for cancelling the case? I would not have cancelled it.

I wouldve proceeded like you did.

Except I wouldnt've put in an a-line.

Old people with broken hips laying unfixed in a bed are at risk of dying from sequelae.....

Sounds like you did a good job to me.

Hemodynamic instability happens sometimes, Dude. Doesnt mean you did something wrong if it happens.

Hip dude probably had some blood loss, starting HCT around 36....may be below 30 now....needs some pressors acutely and some PRBCs in the ICU...no big deal...

And you addressed it like a champ when it happened.

Just next time (emotionally) STEP UP TO THE MIKE WITH MICATIN. YOUR CLINICAL DECISIONS WERE SPOT ON. BELIEVE IN YOURSELF. LEARN TO THINK ABOUT THE GREAT SPAGHETTI YOUR S.O. HAS WAITING FOR YOU WHEN S HIT HITS THE FAN. REMOVE THE DRAMA.

Crashing patients are part of our biz.

Most of the time we fix them, all the while thinking about what we're gonna have for dinner. Or the AAPL stock bought at 160 thats now 179 and change...

Yield THE FORCE.👍

 

[kmurp]

Honestly, other than the hypotension at the end (that is very atypical in my experience), this kind of case is an almost daily occurrence at our community hospital. That is, the hips get done after office hours because the ortho guys are too busy to do them in the daytime. They are very often sick (though this one was a sicker than normal), they VERY often have poor IV access etc etc. I have often found them difficult to intubate due the ortho bed and their old age (if they have teeth). We have been doing the supine cases with LMAs of late. Your approach to induction was OK, in that you lowballed the drugs. I often find 2 versed, 2 fentanyl and 20-30 propofol is enough. Then Sux if an ETT is desired. I generally avoid a long acting relaxant prior to the ETT due to the above mentioned intubation potential problems. By the way: it could have been worse- I lost a patient like this who I could not intubate 1 month into private practice......
As far as the cause of this "event": I don't know-kind of a good ABG for an embolus no? Our arrests around here have all been intraop during cemented bipolars around the time of cementing. If this was not a bipolar, there really shouldn't have been alot of blood loss but i wasn't there so... Generally we never figure these things out.

 

[Apollyon]

And a hospital that doesn't have Dilaudid? What state are you in?

 

[coprolalia]

What was the end-tidal CO2 when the BP dipped at the end of the case? I find that the problem with these patients is usually volume. If he'd had HD before the surgery, I probably would've given a crap-load of phenylephrine instead of ephedrine or epi. If they are volume depleted, you give (even a little morphine) and you dilate out their vascular reserve. BOOM! Crumping BP. I think if you'd dropped in a TEE probe at the end, you would have seen a completely flat LV at maximum systole.

Also, you probably could've done the spinal. If the patient was on heparin gtt, then lovenox was not the issue. And, you coulda definitively found out when the last dose was by checking the chart. Likely that it was at least >24 hours ago, especially if he was on unfractionated heparin. the coags were otherwise acceptable at the time of the surgery. But, this still would've have given you the BP problems with the peripheral vasodilation and probable low-volume status. Ironically, this guy probably could've used a little volume (taboo, I know, in an ESRD patient). Plus a creatinine of 9 is not that unusual in an ESRD patient, and nothing to worry about if the K+ was in a good range.

I probably would've done the case too. You were in a tough spot. Sounds overall like you handled it well. It's a master/servant relationship. Guess who is the servant? 😉

-copro

 

[Intrathecal]

Thanks for the great replies and encouragement guys. Yeah I decided to place the a-line due to this man's obstructive sleep apnea plus poor cardiac status. I wanted to at least give him a chance at extubation at the end of the case so I figured an a-line may have helped me in working towards extubation since I didn't know how sensitive he was going to be to muscle relaxants. I am actually REALLY glad that I placed that a-line because otherwise there would have been a delay in detecting the precipitous drop in BP.

Yeah this man is a fly-weight, around 60kg, so 30 mg roc is the correct dose. It's not the rapid sequence dose but I wanted to give as little as possible given his renal issues.

As for the ETCO2, there wasn't a huge drop, it was in the high 20s I believe and I kept it around 32-33 during the majority of the case. Embolus is still high on my differential given the sudden drop and the timing of the event. But I agree it could have been anything including hypovolemia... and no we don't have TEE since we can't even get dilaudid or etomidate. Histamine release from my whooping dose of 1 mg of morphine seems unlikely. He still might have had a huge MI and I hope he had some enzymes drawn to rule that out, but there were no ST changes on my monitor. I gave 500cc of NS during the case which only lasted ~ 1hr. Not much blood loss to speak of maybe 100cc at most. Not sure if I would've given him anymore and give him pulmonary edema.

Well, I have another full OR schedule today and anther ortho add-on at 3:45. At least this time it's on a 21 yr old. Wish me luck.

 

[leviathan]

There is no right answer, but I'll give you my opinion.

That teeny tiny 20" IV is plenty to get you through if the ortho dude is deft. After he's asleep, if you're uncomfortable, stick away....look at the EJs...

Your comment about your hospital not having etomidate/cisatracurium.....etomidate, because of anesthesia myth propegated by our residency programs, somehow has garnered superiority over propofol when hemodynamic instability is suspected to occur with induction...

...even though etomidate has been linked to mortality increase....

so propofol-or-some-other-induction-agent will do just fine....actually a better choice.......just in smaller doses.

You couldve given propofol right off the bat which wouldve avoided your struggle.....30mg roc? Thats great. Turn your O2 up all the way, turn your sevo up to about 4, and mask away for a cuppla minutes......sub-intubating doses of roc work well....ya just haffta wait a little longer and get a little gas on board while masking, then intubating conditions are OK.

As for your lack of cisatracurium....use vecuronium or rocuronium (like you did) whose primary route of elimination is hepatic glucuronidation....or use no neuromuscular blocker for maintenance (you can use sux for induction on a dude like this, btw).....just turn your sevo a little higher....

As for cancelling the case? I would not have cancelled it.

I wouldve proceeded like you did.

Except I wouldnt've put in an a-line.

Old people with broken hips laying unfixed in a bed are at risk of dying from sequelae.....

Sounds like you did a good job to me.

Hemodynamic instability happens sometimes, Dude. Doesnt mean you did something wrong if it happens.

Hip dude probably had some blood loss, starting HCT around 36....may be below 30 now....needs some pressors acutely and some PRBCs in the ICU...no big deal...

And you addressed it like a champ when it happened.

Just next time (emotionally) STEP UP TO THE MIKE WITH MICATIN. YOUR CLINICAL DECISIONS WERE SPOT ON. BELIEVE IN YOURSELF. LEARN TO THINK ABOUT THE GREAT SPAGHETTI YOUR S.O. HAS WAITING FOR YOU WHEN S HIT HITS THE FAN. REMOVE THE DRAMA.

Crashing patients are part of our biz.

Most of the time we fix them, all the while thinking about what we're gonna have for dinner. Or the AAPL stock bought at 160 thats now 179 and change...

Yield THE FORCE.👍

Hahaha, you should be a motivational speaker, Jet. 👍

 

[Planktonmd]

I am not sure why you had to intubate this guy??
Here is how I would have done it:
Propfol + Lido + little Fentanyl ------> LMA and spont. breathing.
No need for A line.
While the patient is asleep you can look for a better IV if you feel you might need it.
At the end do a fascia iliaca block and wake him up.
The hypotension you saw is possibly caused by sudden increase in PA pressure at extubation (I bet he was coughing and bucking).
This is a simple case if you wanted it to remain simple, delaying the case will not help the patient, you will still have to do it and the co-morbidities would still be the same.

 

[tussionex]

And a hospital that doesn't have Dilaudid? What state are you in?

wow, your hospital's pharmacy dept needs an a$$-kicking!!

 

[Planktonmd]

I figured an a-line may have helped me in working towards extubation

Could you elaborate on how an A line could help you extubate some one?

 

[deleted126335]

.

 

[Noyac]

I agree with most folks here. Don't cancel. Use propofol in small doses, I rarely ever use etomidate any more. Place LMA.

Or place a spinal with guy lying on the broken hip and some sedation ( I like ketamine for this). Give a small spinal dose around 10mg bupiv and 20mcg fent. Hold him with the hip down for about a minute then position him and off you go.

I had a very similar pt, just much younger, for the same case a few years ago who eventually died from the fat embolism w/c hit just as I woke her up. She was talking to me when it happened. She made it to the ICU and lasted about 3 days. Huge p waves on ECG. Did you get an ECG? Cardiologist said this is classic fat embolism.

 

[Strength&Speed]

a few minor points-i dont claim expertise, just something to think about.

i wouldnt think an inr of 1.3 and ptt in 40's would cancel neuraxial, but i'll defer to you guys

I believe cop was suggesting the morphine caused some peripheral dilation and venous pooling that dropped bp, not necessarily a histamine related response. but i agree that 1 mg shouldnt cause such a drastic change.

i agree that that is one hell of a good ABG if it really was such a hemodynamically significant fat embolus.

 

[Intrathecal]

So patient was extubated on POD1 and doing well. I saw him again on POD2 and he was completely neurologically intact and everything was good. Well I guess good is a relative term but he was back to baseline.

It does sound like he may have had acute RV failure from increasing PA pressures from hypercarbia due to attempting spontaneous breathing.

I agree that the ABG was good, but it was drawn after the patient was stabilized with the epinephrine and after I put him back on positive pressure ventilation. The epi did a good job of raising both his HR and BP, and maybe caused the embolus to pass.

I thought an a-line would be helpful in extubation since I can look at his PaCO2, acid/base status, and oxygenation on a particular FIO2 to see whether he has significant V/Q mismatch from pulmary edema or whatnot.

If he was significantly acidotic and hypercarbic, even without the sudden drop in BP, I probably wouldn't have extubated him given his history of obstructive sleep apnea and pulmonary HTN.

As to why not use a LMA with this case... well the only thing was I wasn't sure how long this surgeon was going to take with a hip ORIF. I am used to 3-4 hr fixations with 1L of blood loss so I figured I would secure the airway with an ETT so if the patient needed lots of fluids or blood that might cause him to have pulmonary edema, at least I would be able to use controlled ventilation and PEEP to optimize oxygenation.

The issue with the spinal was not just the questionable coagulation status, but also with his cardiac (EF of 30%) and renal issues and unknown volume status, I didn't want an uncontrolled sympathectomy and vasodilation if he was already hypovolemic and it would be difficult to give him fluids without causing overload. It's really a tough balancing act, but I guess it could be done. I just didnt' want to risk it.

I got my butt kicked again the following call night, I did cases until 1:30am. Apparently it has been an usually busy week. Lucky me I guess. I am just glad the patient didn't have a bad outcome on my second night of call. Hopefully next week the hours will be better.

On the upside, I got my paycheck today from my first week of attending ship, and it was pretty nice. That certainly brightened up my day 😀

 

[Noyac]

The epi did a good job of raising both his HR and BP, and maybe caused the embolus to pass.


The issue with the spinal was not just the questionable coagulation status, but also with his cardiac (EF of 30%) and renal issues and unknown volume status, I didn't want an uncontrolled sympathectomy and vasodilation if he was already hypovolemic and it would be difficult to give him fluids without causing overload. It's really a tough balancing act, but I guess it could be done. I just didnt' want to risk it.😀

Just to clarify, would you explain the increase pressure causing the embolus to pass. Pass what? Clot Embolus or are we still talking fat embolus? These are two different things as far as I am aware.

Have you ever tried a unilateral spinal? They can be very stable. I just did one this evening on a very similar pt. BP dropped about 5 pts thats it.

 

[Burnt2]

Interesting case, thank you for sharing it

 

[2ndyear]

Just to clarify, would you explain the increase pressure causing the embolus to pass. Pass what? Clot Embolus or are we still talking fat embolus? These are two different things as far as I am aware.

Have you ever tried a unilateral spinal? They can be very stable. I just did one this evening on a very similar pt. BP dropped about 5 pts thats it.

By unlilateral, you mean hypobaric with water, affected side up?

 

[Noyac]

By unlilateral, you mean hypobaric with water, affected side up?

Thats one way but I find it easier to sedate with 2mg versed and 5-15 mg ketamine. Roll the pt on the affected side (broken hip down) crunch them up somewhat with the top leg up towards the abdomen and shoulders down in a semi fetal position. The ketamine keeps them breathing perfectly and I use the heavy bupiv from the spinal tray. About 10mg with some fentanyl or duramorph depending on the pt. Keep the pt with the affected side down for about 1 minute then position them on the OR table. The ketamine only lasts about 5-10 minutes. My pt last night looked at me when I was done and said she was on a tropical island, could I send her back there.
Ketamine gets a bad rap from time to time but I almost never see that. Maybe I use it differently.
Many use propofol for this instead of ketamine and in these old folks just 2cc of propofol is enough from time to time to make them stop breathing for a few minutes.

 

[Planktonmd]

I figured I would secure the airway with an ETT so if the patient needed lots of fluids or blood that might cause him to have pulmonary edema, at least I would be able to use controlled ventilation and PEEP to optimize oxygenation.
😀

I didn't know that you can't use controlled ventilation and PEEP with an LMA!
Is there a specific reason?

 

[ALTorGT]

once a gomer is past the point of making urine and his kidneys have failed, is the creatinine reading of any significance? what we're interested in is what the electrolytes are doing...which should be normal if he's had dialysis withn 24 hours ish.
creatinine is a marker of kidney function, but a high creatinine level in and of itself is of dubious value?

 

[CanGas]

I would have done a low dose spinal as well.

Put on monitors and O2. Put 2 mg (2cc) Midaz and 30 mg (3cc) Ketamine into a 5 cc syringe. Give half and wait to circulate, that is usually enough for these old, sleep deprived patients, if not give the other half. Then turn the patient broken side DOWN. Upper good leg is flexed at the knee and pulled up to the chest, head and shoulder are pulled down into a semi-fetal position. They may moan a bit when first turned but they remember nothing, keep breathing and the BP does not change. The idea of bad hip down means that leg is anchored and stabilized by lying flat on the bed. Bad side up means the fracture is grinding back and forth every time you wiggle the patient a bit.

Normal coags in a old person I use a 24g Sprott (rare to get headaches in this population) and the bigger needle makes it easier to find the space. If no 24g available I use a 25g Quinke (cheaper than a whitacre). In this case with an INR of 1.3 I would have used the same procedure but with a 27g needle after having a discussion with the patient and family regarding the risk-benefits. If closer to an INR of 1.5 I would have put the patient asleep as you did. I would not do an epidural at an INR of 1.3.

If your surgeon is slow ie. 2hrs or so would give 10 mg Isobaric 0.5% Marcaine. If they are a decent speed I use 7.5 mg of Hyperbaric 0.75% Marcaine and leave them on their side for 5 min. It takes 20 min for hyperbaric to "set" fully but I find 5 is enough for me. Not sure I am brave enough for only 1 min like Noyac uses but perhaps I will try it some day. Probably ok if the patient will be supine as it will stay in the area but I am not sure if 1min is long enough if will be lateral with broken hip up. If I am not sure about the surgeon I will add some narcotic to the spinal but I generally find the patients are comfortable enough post-op without so leave it out to avoid side-effects.

From keeping track of PACU records (time to first motor, time to first narcotic):
With 10 mg Isobaric 0.5% Marcaine I get about 2hrs motor block in old folks, 1.5-2 hrs in younger.
With 7.5 mg Hyperbaric Marcaine unilateral I get about 1h15min-1hr30min motor block on affected side in old folks (about 45min-1hr in younger, good for arthroscopy and patient wants to watch the screen).
In both cases analgesia generally lasts an additional 1 hr (usually need no narcotic in PACU) (for hip surgery, different for knee or ankle). Addition of narcotics seems to add about an additional 1 hr of analgesia to the above.

These doses are extremely hemodynamically stable. BP really does not budge much. For example, while I would not offer this as an answer for the Royal College exam, I did a I&D of a hip post THR on a guy with Moderate AS (AVA 0.8) with 7.5 mg Hyperbaric Marcaine as above. I probably would not have been ballsy enough to do that from the start but the guy got his THR 3 weeks earlier with a bigger dose spinal with no problems (the 1st anesthetist did not have the AS history and Echo) so I figured I would be safe

Just some recipes for your arsenal. Use them with caution and judgment and discretion and not for all, blah blah blah. Lawyers stay away.

CanGas

Thats one way but I find it easier to sedate with 2mg versed and 5-15 mg ketamine. Roll the pt on the affected side (broken hip down) crunch them up somewhat with the top leg up towards the abdomen and shoulders down in a semi fetal position. The ketamine keeps them breathing perfectly and I use the heavy bupiv from the spinal tray. About 10mg with some fentanyl or duramorph depending on the pt. Keep the pt with the affected side down for about 1 minute then position them on the OR table. The ketamine only lasts about 5-10 minutes. My pt last night looked at me when I was done and said she was on a tropical island, could I send her back there.
Ketamine gets a bad rap from time to time but I almost never see that. Maybe I use it differently.
Many use propofol for this instead of ketamine and in these old folks just 2cc of propofol is enough from time to time to make them stop breathing for a few minutes.

 

[proman]

re: creatinine and ESRD/HD.

Once a patient is on HD, the creatinine isn't used as a marker for anything. BUN is a more reliable marker of effectiveness of dialysis (in addition to volume status and electrolytes). The BUN may normalize (or be slightly higher) but the creatinine will not. So, a high creatinine in an HD patient means nothing.

 

[dhb]

Under 10mg of marcaine you rarely see a change in bp. I've used as low as 6mg isobaric for old gomers for hips. Haven't done the lateral spinal yet but i'm sure you can get a good 1.5h of analgesia with 5mg of hyperbaric if you leave the patient on the side for 5min. 1 min seems a bit short do you see changes in bp in frail patients with this technique?
I love to give them 20-25mg of K to transfert them from the stretcher to the or table if you're not too slow it gives you time to roll them to the room and sit them up for the spinal.
It's awesome to have them space out, everybody give you the looks like wtf is the dude dead, then you slap the pulse ox on and it always reads 99 😀

 

[potentagent]

There is no right answer

That about sums it up, it is your license = your call.

 

[Noyac]

That about sums it up, it is your license = your call.

What if things go terribly wrong?

Then is there a right answer?

 

[jetproppilot]

What if things go terribly wrong?

Then is there a right answer?

WOW!!! GETTIN PHILISOPHICAL, HUH MIKEY????


so heres a little philisophical s hit right back atcha...


If one searches the Vatican's chronicles, one will find that there is only ONE TRUTH.

If a (truly) well trained anesthesiologist is true to himself, brings his best work to the table in a dire situation, and acts deftly in accordance to his knowledge, training, and astute decision making in the best interest of the patient and things go terribly wrong,

THATS THE BREAKS. OUTTA YOUR CONTROL (which if ya really are attuned we arent in control).

You know you practiced like a rokkstarr.

And so does God.

Thats the TRUTH.

F ukk the lawyers.

Thats why we have malpractice insurance.

In this business we all know and love,

YOU CAN'T BE SCARED TO DO YOUR JOB WHEN THE CHIPS ARE DOWN. EVEN AT THE RISK OF FAILURE.

To do so would cripple our clinical work.

 

[Noyac]

If one searches the Vatican's chronicles, one will find that there is only ONE TRUTH.

Every religion states that there is but one truth. But they all seem to have different truths to some degree. So Jet, I ask you. How do we know what the TRUTH really is?

How come we think our truth is "the TRUTH". Because that is how we were raised by our parents, or mentors. But did you ever ask them how they came to know "the TRUTH"? Or did you just accept it as "the TRUTH"?

And who wrote the vatican's chronicles anyway? A man. Come on man, don't give me that religion crap. 😀 We all know that it is faith based and faith is just that, FAITH. Nothing more.

But at least in medicine we have a little proof at times. And this is what makes some better than others, our knowledge of these truths which come from proof.


OK big guy. Beat me down.😍

 

[Gern Blansten]

Bingo!!!

I was playing the Jetprop SDN bingo game and my winning card is as follows:

In the diagonal direction from the top left to the bottom right:

In the "B" column, I had "step up to the mic with micatin"
In the "I" column, I had "any variation of the word 'deft'"
In the center free square, I had "the anesthesiology myth"
In the "G" column, I had "any variant spelling of the word 'rockstar'"
And for the win, in the "O" column, I had "refers to Noyac as Mikey"

🙂
Just having fun with you Jet!

 

[Intrathecal]

I must admit I have never tried a unilateral spinal myself... will give it a try next time we do one.

I also have to admit that there are a few techniques that I feel I am ill prepared for from residency. Besides the unilateral spinal, I needed to do an axillary block for a wrist fracture ex-fix the other day. We don't have an ultrasound at this hospital (big surprise huh?), and the last time I did one of those without an ultrasound was early CA-2 year.

I had to review it on nysora, but the block worked great but definitely took longer than with an ultrasound guided supraclavicular block, which would have taken less than 5 minutes. The patient also didn't like the tourniquet going up much since I didn't block the musculocutaneous n. which may have branched off already above the brachial plexus where I injected local. In the end I was able to do the case with just the block and propofol infusion.

In answering someone's question earlier about the clot passing, my rationale is that epinephrine causes an increase in cardiac contractility causing more forward flow of blood. Therefore if there was an embolus... whether it be a clot or fat, sitting at the bifurcation of the PA, the increase in forward flow may have been able to push the embolus through. But like someone mentioned it would also be totally plausible that he had acute RV failure from worsening pHTN due to hypercarbia, and in that case epinephrine would have worked also but milrinone may work better in that situation. That reminds me I have to check on the availability of that drug at my hospital... wouldn't surprise me if they don't have it.

And in terms of the LMA with positive pressure and PEEP, sure you can do it for a certain amount of time. But LMA may cause ischemia/necrosis of the structures around the periglottic area if used for a prolonged period according to some sources. I wasn't sure that this patient was going to be able to maintain a patent airway after the procedure with h/o OSA and pulm HTN. I thought that the likelihood of this patient remaining on PPV was high and so I opted to place a tube.

I do agree that I took a very conservative approach to this case. I do appreciate everyone's input on what other methods could be used. This is what makes this forum a very valuable tool. 👍

 

[Noyac]

Is a fat embolism a large piece of fat floating in a vessel towards the heart and ultimately the pulmonary artery? Or is a fat embolism multiple fat globules causing a vascular and pulmonary response?

 

[jetproppilot]

Every religion states that there is but one truth. But they all seem to have different truths to some degree. So Jet, I ask you. How do we know what the TRUTH really is?

How come we think our truth is "the TRUTH". Because that is how we were raised by our parents, or mentors. But did you ever ask them how they came to know "the TRUTH"? Or did you just accept it as "the TRUTH"?

And who wrote the vatican's chronicles anyway? A man. Come on man, don't give me that religion crap. 😀 We all know that it is faith based and faith is just that, FAITH. Nothing more.

But at least in medicine we have a little proof at times. And this is what makes some better than others, our knowledge of these truths which come from proof.


OK big guy. Beat me down.😍

ALRIGHT, MY FRIEND. HERE IT COMES.

(seriously, no kidding) Jet puts down computer for a minute, pours a big glass of CAYMUS cab, puts in a big dippa Copenhagen and returns to computer

And this is gonna expose more of me than I really want to, but thats OK.

Mikey, I'm a doubter by nature when it comes to religion. Yeah, I was brought up catholic. Went to catholic school for mosta my education.

Then I went to college. Majored in science. Learned about the whole evolution thing.

"I'm a scientist!" I thought during my education.

Made my catholic beliefs (or if you are jewish/buddhist/whatever, insert your religion where I put catholic) seem like a crokka s hit.

So my faith stopped for a period of years.

Then, during the early years of my private practice life I was witness to several cases in the OR that had no other explanation than God.....or whatever your higher power is.....was at work.....kinda like He was saying......"UHHHH DUDE, WTF???...wish wanna the computer savvy dudes here could sift thru and find it...

I've posted a cuppla them, the most dramatic being a dude about my age, a small-county sheriff, who showed up in the ER with an acute MI....ended up in our OR......and......I'm convinced.....DIVINE INTERVENTION is why that man is living today.

Not the heart surgeon (T Mack Granger...you could call him RIGHT NOW and he'd remember...just mention the buzz words SHERRIF, CODING, DEAD, WORKED OUR ASS ES OFF TO NO AVAIL, LIMPED OFF BYPASS, DUDE WAKES UP, WALKS OUTTA HOSPITAL.....T Mack (and I) would recall dudes name immediately...) and staff.

Not me and my deft CRNA (Paul Greer).

My interpretation of that incident is GOD decided that guy was not to die that day.

Which changed my scientist, evolutionary theory life.

I do not believe we are in control.

Yes, we strive to make the best decisions in our lives.

We fail alot.........hence defining us as human beings.

I think it is micromanaging to think that this.....our reality....our lives.....

IS IT.

Humans have come a long way! We've entered space and have appreciated the vastness of our galaxy....

I don't believe this is it.

I believe there is a Higher Power at work.....for me, personally, that Higher Power is God, and his Son, Jesus Christ.....whom He sent to our reality so we could relate.....who loves us when we make mistakes......

Yeah, Mikey, a man wrote the Vatican chronicles.

I believe it was divinely narrated.

Lemme ask you a question....

Have you ever been in a situation where your "instincts" have steered you in the right direction?

Where you look back at said situation and say "GEEZ.....that was a close one....I, for the life of me can't explain why I acted like I did, but I sure am glad I made THAT decision....."

I don't believe those are our "instincts" at work, Bro.

And with that, I return to the OR cases that changed my opinion of evolution verses Divinity.

I wish you couldda been there.

Really.

It wouldve changed your thinking on the whole FAITH thing too.

Yes.

Us humans are highly evolved beings.

I think it is shortsided to think that WE ARE IT.

So returning to your question about FAITH.....

I have faith, Mike.

I've personally witnessed His work.

I wish you couldda been there.

I'm obviously not a bible-clenching dude thats in your face about religion like the dudes that awaken you on a Sunday morning after your night with Patron Reposado.

But I DO recognize that I'm not IT. You're not IT. We aren't IT.

Theres a Higher Power at work.

Jet exhales. Spits in the Crystal Light container-turned-dip-cup. Takes a big sippa CAYMUS.

BETCHA TRINITYALUMNUS REMEMBERS THAT CASE.

 

[Noyac]

Nice Jet, very nice.
To answer your question about instincts. I feel instinct comes from experience. That is not to say some force or even God is not waving his hand over us at that moment. But our experiences are what help us make our decisions. We are not always aware of why we act but we do and we get better and better as we experience more and more.

Now let me ask you something. Can you remember a time when you made a decision which you wish you had not made? Your instincts now come from that wrong decision.

Let me put it this way, I'm not a non believer. Just last night a deer jumped out in front of my truck of the way home from my hip fx case. Somehow I missed him or he missed me. As soon as I realized what happened it was over and I said "Thank You God". And not just in the casual sense. So I am not a non believer. I just have a hard time believing that any one religion is better than the other or more right than the other. Why would God pick christianity over Buddism or Islam, or Judaism, etc.

What if there is more of a force which is made up of all of our souls? We are all a part of GOD. What if?

 

[jetproppilot]

Bingo!!!

I was playing the Jetprop SDN bingo game and my winning card is as follows:

In the diagonal direction from the top left to the bottom right:

In the "B" column, I had "step up to the mic with micatin"
In the "I" column, I had "any variation of the word 'deft'"
In the center free square, I had "the anesthesiology myth"
In the "G" column, I had "any variant spelling of the word 'rockstar'"
And for the win, in the "O" column, I had "refers to Noyac as Mikey"

🙂
Just having fun with you Jet!

Ya got me bro.

Time to buy a Powerball ticket. 👍

 

[jetproppilot]

Nice Jet, very nice.
To answer your question about instincts. I feel instinct comes from experience. That is not to say some force or even God is not waving his hand over us at that moment. But our experiences are what help us make our decisions. We are not always aware of why we act but we do and we get better and better as we experience more and more.

Now let me ask you something. Can you remember a time when you made a decision which you wish you had not made? Your instincts now come from that wrong decision.

Let me put it this way, I'm not a non believer. Just last night a deer jumped out in front of my truck of the way home from my hip fx case. Somehow I missed him or he missed me. As soon as I realized what happened it was over and I said "Thank You God". And not just in the casual sense. So I am not a non believer. I just have a hard time believing that any one religion is better than the other or more right than the other. Why would God pick christianity over Buddism or Islam, or Judaism, etc.

What if there is more of a force which is made up of all of our souls? We are all a part of GOD. What if?

And there I am with you.

Wanna my best friends on the planet is Jewish.

Went to med school together.

We've had the christian verses jew debates.....some heated, but hey, we're friends (and this is a dude who could squat 500 to da floor, STONED OUTTA HIS MIND in college....we worked out religiously together during med school at DA U.....messing with him would definitely scar my pretty face )

We've decided we're both good people with respectable faiths.....we're not smart enough as humans to sort out the religious differences....

we both believe in God.....

we leave the rest for someone else to figure out.....

 

[jetproppilot]

Bingo!!!

I was playing the Jetprop SDN bingo game and my winning card is as follows:

In the diagonal direction from the top left to the bottom right:

In the "B" column, I had "step up to the mic with micatin"
In the "I" column, I had "any variation of the word 'deft'"
In the center free square, I had "the anesthesiology myth"
In the "G" column, I had "any variant spelling of the word 'rockstar'"
And for the win, in the "O" column, I had "refers to Noyac as Mikey"

🙂
Just having fun with you Jet!

Now that I'm outta my serious, philisophical mode,

HAHAHAHAHAHAHAHAHAHAHAHAHAHAA

Thats hilarious, Dude!!!!!

Thanks for that.👍👍

 

[radslooking]

once a gomer is past the point of making urine and his kidneys have failed, is the creatinine reading of any significance? what we're interested in is what the electrolytes are doing...which should be normal if he's had dialysis withn 24 hours ish.
creatinine is a marker of kidney function, but a high creatinine level in and of itself is of dubious value?

yes, i agree with that. bun is better estimate of clearance. and lytes far outweigh any cr. reading.

 

[Planktonmd]

And in terms of the LMA with positive pressure and PEEP, sure you can do it for a certain amount of time. But LMA may cause ischemia/necrosis of the structures around the periglottic area if used for a prolonged period according to some sources.

I Humbly disagree.
Whenever wide hemodynamic changes are a concern or whenever you have a patient that will not handle the level of anesthesia needed to tolerate an ETT an LMA is the way to go, and all these anecdotes about not doing long cases with LMA and not doing mechanical ventilation with LMA are unsupported.

 

[jetproppilot]

I Humbly disagree.
Whenever wide hemodynamic changes are a concern or whenever you have a patient that will not handle the level of anesthesia needed to tolerate an ETT an LMA is the way to go, and all these anecdotes about not doing long cases with LMA and not doing mechanical ventilation with LMA are unsupported.

Agree with Plank here.

Hate it when I say "Lets use an LMA."

Colleague replies "Can't. Its a three hour case."😕

 

[huktonfonix]

BP drop could also be attributed to the change in leg position depending on if the leg was raised during the surgery kinda like dropping the legs after a uro procedure especially if he was dry to begin with.

 

[ZA_Gasman]

To throw another spanner in the works here, and apologies if I missed it, but what about using LMA in the context of increased aspiration risk (which we have here with ESRD) Just shaking the tree to see what falls out, I'd prob risk:benefit it, and would prob come down on the side of an LMA (or the mythical Proseal..)