New CA-1 Case: Dressing Change

[OB1🤙]

For the incoming CA-1s about to start the first day of the rest of their lives- congrats on being done with the obnoxiousness of intern year. It sucked, I know, but you learned a lot, and the medicine you absorbed will serve you well as you move on to your chosen career.

So you made it. You're a CA-1. Huge congrats. Now here's a case for you.

Add-on slip is dropped for a 60 y/o guy, 5'6" and just short of 300 pounds, for an abdominal dressing change in the OR. Had an incarcerated ventral hernia repaired a few weeks back, complicated by incisional wound breakdown and dehiscence, and now has a large open defect from umbilicus to xyphoid, with mesh still overlying the peritoneum. Surgical plan is to explore wound, change dressings and wound vac, should take anywhere from 30 minutes to an hour.

Anything more you want to know, and how do you proceed? Med studs, play along too.

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[aphistis]

#1: Track down AR for the VHR, find out what was planned for that procedure and how successful it was. If it went smoothly, any anesthetic plan that was good enough for the original repair will be sufficient for this procedure. If it didn't, start looking at other options.

 

[Jeff05]

i would like medical history. allergies. airway exam. last K+.

 

[aphistis]

Do you routinely do this?

Look at recent anesthetic records? Of course, if they're available. You don't necessarily have to do it the same way, and it doesn't absolve the need to do your own H&P, but it's a good place to start. Particularly for someone just beginning their training, would you recommend against doing it that way?

 

[OB1🤙]

i would like medical history. allergies. airway exam. last K+.

History of well-controlled DM2, gastric bypass a couple years ago, otherwise no significant PMH. Has been on trickle tube feeds via dobhoff, feeds off since midnight. NKDA.

Airway exam- MP3, FROM, TMD>3 FB.

Last K 4.8. He's been stuck in bed for a couple weeks since the hernia repair. On abx, insulin SSI, and a dilaudid PCA.

Last anesthetic record is available for viewing online- easy mask with oral airway, RSI with glidescope, easy intubation.

Attending surgeon rolls by and says "we usually just do this kind of thing under MAC. This won't take long and shouldn't be too painful."

 

[mstudent12345]

Soon to be Intern but I'll give some thoughts.

1) This guy's airway is ok not great, and with the obesity it can go to sh-- fast, so while MAC might be "nice" for the surgeon I want that airway dealt with upfront. Also considering he's fat is FRC is 0

2) That K is kind of highish, what's up with the rest of his labs, how bout his vitals --> he's got an abd wide open, is he spiking, hypotensive, acidotic what else

3) Lastly how's his heart. I know it probably isn't worth anything but is his EKG normal.

4) Oh hes also been on a dilaudid PCA, so while "it may not be too painful" he is clearly already in pain and has a very high tolerance.

I'd start with that but my guess is another RSI, general gas, and try to use the PCA last 24 to guide me as to his basline narc requirements.

History of well-controlled DM2, gastric bypass a couple years ago, otherwise no significant PMH. Has been on trickle tube feeds via dobhoff, feeds off since midnight. NKDA.

Airway exam- MP3, FROM, TMD>3 FB.

Last K 4.8. He's been stuck in bed for a couple weeks since the hernia repair. On abx, insulin SSI, and a dilaudid PCA.

Last anesthetic record is available for viewing online- easy mask with oral airway, RSI with glidescope, easy intubation.

Attending surgeon rolls by and says "we usually just do this kind of thing under MAC. This won't take long and shouldn't be too painful."

 

[Mman]

I'm just saying that it is usually a pain in the ass to get the old record (at least at the hospitals I've been at) and so I don't start there.

Computerized anesthesia records are a god-send for reasons like this. Spending 2 minutes clicking through every relevant detail of their last several anesthetics is extremely useful and efficient. It also beats trying to read bad and small handwriting and abbreviations on a hand written record that is hard to track down.

 

[OB1🤙]

1) This guy's airway is ok not great, and with the obesity it can go to sh-- fast, so while MAC might be "nice" for the surgeon I want that airway dealt with upfront. Also considering he's fat is FRC is 0

That's certainly a reasonable argument. Do you feel strongly enough about it to pick this case as a battle with the surgeon?

2) That K is kind of highish, what's up with the rest of his labs, how bout his vitals --> he's got an abd wide open, is he spiking, hypotensive, acidotic what else

Is the K high? Does it matter? Other labs and vitals are within normal limits. Afebrile, on abx but certainly not septic.

3) Lastly how's his heart. I know it probably isn't worth anything but is his EKG normal.

Recent stress echo and EKG are unremarkable.

4) Oh hes also been on a dilaudid PCA, so while "it may not be too painful" he is clearly already in pain and has a very high tolerance.

This may be true, but you can't say it with certainty. He has a PCA, but we don't know anything about its use yet. As it turns out, he only rarely pressed the button and there was no background infusion.

I'd start with that but my guess is another RSI, general gas, and try to use the PCA last 24 to guide me as to his basline narc requirements.

What agents are you going to use for your RSI, and what doses? Why? What potential concerns are there for this approach for this patient?

Anyone feel a MAC is a safe option here? If so, what's your approach?

 

[ssmallz]

That's certainly a reasonable argument. Do you feel strongly enough about it to pick this case as a battle with the surgeon?

Is the surgeon really going to care? Most surgeons I've met don't really mind if you pop an LMA in there as long as the case doesn't get delayed. That'd be my vote btw, why make trouble for yourself w/a guy whose fat and has potential for airway issures. If the surgeon was truely insistant on a MAC case I'd do it with the implication that if anything starts to go wrong this dudes gettin an LMA.

 

[Arch Guillotti]

I would not use an LMA on this guy. He's 300 pounds with a belly problem and sounds like he's been laying around awhile getting some narcotics. You probably could get by with an LMA but my personal preference is ETT.

The case conceivably could be done under MAC but it couldget kind of unpleasant. You could assess his narcotic tolerance by incrementally dosing him with some fentanyl while you are getting ready to go to sleep/sedation. If you end up pushing 10 cc's of fentanyl and he hasn't batted an eye then geta is the way to go.

I have done a couple of these wash out cases under MAC but it can be very challenging. One thing to consider is the possibility of post op ventilation. If the pt has a hx of flunking extubation then you may want to try a MAC.

Personally I would use GETA. Prop, roc, tube.

 

[mstudent12345]

That's certainly a reasonable argument. Do you feel strongly enough about it to pick this case as a battle with the surgeon?

I'd say yes, an LMA makes sense and I'd be uncomfortable doing pure MAC

Is the K high? Does it matter? Other labs and vitals are within normal limits. Afebrile, on abx but certainly not septic.

Recent stress echo and EKG are unremarkable.

Then no, I'm fine with the K but I think these were the next logical questions.

This may be true, but you can't say it with certainty. He has a PCA, but we don't know anything about its use yet. As it turns out, he only rarely pressed the button and there was no background infusion.

Point taken

What agents are you going to use for your RSI, and what doses? Why? What potential concerns are there for this approach for this patient?

I'd say 15mg/KG of prop, and some sux should do the trick. The major danger is the can't intubate/ventilate situation but given that he was ventilated fine in the past I'm not that worried. I'd have the glidescope around though.

 

[Arch Guillotti]

I'd say 15mg/KG of prop,

 

[OB1🤙]

Good answers all.

Is anyone worried about the fact that this dude has been laying in bed for weeks? Does this matter if we're planning on giving sux, or is this a nonissue?

If we give an RSI dose of roc, the procedure takes 30 minutes, and we don't have any twitches back, is this a problem, or doesn't it matter?

 

[aphistis]

I'd say 15mg/KG of prop, and some sux should do the trick.

Only if you're trying to kill him before the surgeon can.

 

[aphistis]

Is the surgeon really going to care? Most surgeons I've met don't really mind if you pop an LMA in there as long as the case doesn't get delayed. That'd be my vote btw, why make trouble for yourself w/a guy whose fat and has potential for airway issures. If the surgeon was truely insistant on a MAC case I'd do it with the implication that if anything starts to go wrong this dudes gettin an LMA.

I would not use an LMA on this guy. He's 300 pounds with a belly problem and sounds like he's been laying around awhile getting some narcotics. You probably could get by with an LMA but my personal preference is ETT.
...
Personally I would use GETA. Prop, roc, tube.

I had a case very similar to this yesterday, and I wanted to to do an LMA for the reasons ssmallz gave. Staff wanted to intubate for the reasons Arch gave, so we intubated. Emergence was miserable, and I had to give the lady a lot of ventilatory help before I could extubate her. I would've been screwed with just an LMA in place. Staff 1, me 0.

 

[Frank Rizzo]

Good answers all.

Is anyone worried about the fact that this dude has been laying in bed for weeks? Does this matter if we're planning on giving sux, or is this a nonissue?

What Bruin is trying to get at is the use of sux in bed-bound, debilitated patients.

True story: 20ish yo male in SICU s/p multiple gsw to abd. Now with numerous fistulas/drains. SICU day 62 and counting. Develops sepsis from a nasty bug and needs intubated. SICU team performs RSI with sux---> patient codes, ACLS started. They got him back after about 5 minutes of ACLS. Stat labs showed a K+ of 9.3, was 4.1 3 hours prior. Hyperkalemic arrest is rare in situations like this, but it does happen.

He got out of the SICU on like day #115, went to a long-term rehab hospital, is supposedly back home getting around the clock care from his family.

The real lesson from this story is don't live the thug-life!

 

[OB1🤙]

I posted this case as an example of something that looks easy as hell when you pick it up (dressing change! sweet! easiest anesthetic ever!), which then turns out to be a nightmare however you choose to proceed.

Wanna intubate? Great. You either take a chance on post-sux hyperkalemia (very unlikely, but as the example above shows, not impossible), or having to wait around for potentially a long time after what will be a nontrivial dose of ROC either in the OR (burning valuable $$) or in the PACU (and who really wants to extubate this patient in the PACU?).

LMA? OK, but if things get hairy on the old ventilation front, you could be up $hit creek sans paddle. LMA supreme might be better than a classic, but either way, it's not gonna be optimal. Doable, but not optimal.

Then there's the way we decided to proceed (and by we I mean my staff, I wanted to intubate). We decided on lower-dose propofol gtt supplemented by nitrous, with the occasional hit of ketamine for more stimulating times. This worked fine, but even with a little glyco, secretions were significant, leading to a lot of coughing, which didn't jive so well with a big open belly and surly men with knives trying to navigate their way around it.

Then there's calling a spade a spade- this really ended up being GA with an unprotected airway, not "deep sedation." I figured in advance this is what it would take to be able to do the case, and was the reason I just wanted to intubate and be done with it, but all in all in worked out. He coughed and coughed and coughed postop though, enough to warrant a CXR, and I think quite a bit of saliva/secretions made its way into the lungs. Eventually this simmered down and he did fine.

He went back yesterday for another dressing change and a different attending decided to do an awake FOI.

 

[dhb]

Wanna intubate? Great. You either take a chance on post-sux hyperkalemia (very unlikely, but as the example above shows, not impossible), or having to wait around for potentially a long time after what will be a nontrivial dose of ROC either in the OR (burning valuable $$) or in the PACU (and who really wants to extubate this patient in the PACU?).

Hem.. how 'bout tubing him without muscle relaxant

 

[Arch Guillotti]

I posted this case as an example of something that looks easy as hell when you pick it up (dressing change! sweet! easiest anesthetic ever!), which then turns out to be a nightmare however you choose to proceed.

Wanna intubate? Great. You either take a chance on post-sux hyperkalemia (very unlikely, but as the example above shows, not impossible), or having to wait around for potentially a long time after what will be a nontrivial dose of ROC either in the OR (burning valuable $$) or in the PACU (and who really wants to extubate this patient in the PACU?).

lol, I thought the case sounded like a POS when I read it. Why is it necessary to use sux on this guy? Has he been a difficult airway in the past? I wouldn't use sux and I wouldn't give 1.2 mg/kg of roc either. I would most likely give 50 of roc and ventilate gently through cricoid pressure (though it may be bunk).

 

[Jeff05]

this guy needs a tube. if you think he's a difficult airway - AFOI.
if you don't RSI. if you don't want to use sux - fine, use roc. the debridement is gonna take 45-60 min - take him to the pacu, vent him for another hour and then reverse/extubate. better than having this patient aspirate.

if you don't want to use relaxant. fine.
glyco 0.3mg
propofol 200mg
remi 1 mcg/kg

you will have perfect intubating conditions without relaxants, most of the time.

 

[Arch Guillotti]

He went back yesterday for another dressing change and a different attending decided to do an awake FOI.

That sounds kind of dumb unless he has a known hx of a difficult airway.

 

[Arch Guillotti]

prop plus some alfenta can also yield pretty good intubating conditions.

 

[Licoricestick]

this guy needs a tube. if you think he's a difficult airway - AFOI.
if you don't RSI. if you don't want to use sux - fine, use roc. the debridement is gonna take 45-60 min - take him to the pacu, vent him for another hour and then reverse/extubate. better than having this patient aspirate.

if you don't want to use relaxant. fine.
glyco 0.3mg
propofol 200mg
remi 1 mcg/kg

you will have perfect intubating conditions without relaxants, most of the time.

Agree that Remi/alfentanil would be a good way to go if you want to avoid relaxants (and I would argue you can protect the airwya adequately even though it isn't strictly speaking an RSI). Even though I love the supremes, I'd be very wary about doing this case without a tube.

Provided I was happy with the airway (and as the previous anaesthetic showed he was easy to bag and used a glidescope without difficulty it sounds good to me) rocuronim 1mg/kg LBW (yes - it's a lower dose, but it's actually the standard RSI dose down here)and chances are its going to wear off in about 45min anyway. Between giving the roc/putting the tube in/prep/drap/surgeons actually starting you're probably looking at 10min, add in the fact that an operation is NEVER as fast as the surgeon says and you're at 60min post roc by the time you want to think about reversing him - betcha you got twitches back by then. And the (very secondary) bonus is - having done it with muscle relaxation the surgeons are happy with their operating conditions.

 

[amyl]

keep it simple: 200 propofol, 100 fent, 50 of roc, tube w glidescope. no sux, no reason. if surgeons say 30 minutes that means an hour. unless there is something missing in the hx that says he won't metabolize roc in time it should be okay. if dead set against ROC, remi is a good idea. not a fan of lma in this dude.

 

[dhb]

if you don't want to use relaxant. fine.
glyco 0.3mg
propofol 200mg
remi 1 mcg/kg

you will have perfect intubating conditions without relaxants, most of the time.

Yes although 4 mcg/ kg of remi is better.