Not your standard Lap Chole

[excalibur]

57 y/o obese (5'10", 100 kg) smoker, with severe COPD (2L at home), CHF, h/o Afib, h/o CABG x 2v with AVR one year ago, AICD, and DM presents for lap chole due to septic gallbladder.

Pt had CABG and AVR one year ago with complicated postop course. Pt required prolonged mechanical ventilation with tracheostomy due to multiple pulmonary complications including pneumonias and possible PTX. Pt required mechanical ventilation for 6 months per family.

Pt in preop holding has a 20 g PIV in right wrist. He is alert, responsive, mild labored breathing. His face appaears cyanotic. Pt on 6L NC. SpO2 84%. BP 90/60. No pressors at this time. Airway: MP III, FROM, teeth intact, visible healed tracheostomy scar.

Labs: h/h 10/30. Na 130. Cr 1.5. K 4.4. ABG: 7.34/50/60 on 6L NC. Coags normal.
CXR: No acute chages from previous CXR. Hyperinflated lungs.
ECG: NSR with occasional PM spikes
Echo: Severe hypokinesis, EF 25%, Severe pulm HTH 65 mm Hg, Moderate AR, and MR.

Surgeon understands pt is a mess, but states that if the gallbladder doesn't come out that the patient will die as it is not responding to conservative antibiotic therapy.

Plan?

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[VentdependenT]

Perc Cholecystostomy

 

[ctsicu]

Awake FOI if aw difficult, otherwise long preox, RSI with FOB avail. Explain to family and pt high likelihood of remaining intubated post op. would be a little nervous abt lap case in this pulm htn pt and given the abg numbers--??open;
monitors-Aline, central line, poss TEE if problems;

 

[ctsicu]

Agree with vent tho but sounded like that was not an option?

 

[ctsicu]

Sorry would also have some inotropes avail.

 

[G0S2]

Pre induction art. Glidescope for airway and may need smaller tube. Treat case like a heart with low ef with PAC and milrinone. Family needs to understand he may be on blower for a long time and trached again.

 

[VentdependenT]

This dude is hosed on so many levels. Curious as to how it went down. Defib pads should be on for whole case for sure.

Open chole would smoke this dudes resp mechanics. If extubate, then extubate to bipap.

 

[fakin' the funk]

Wow. Nice case.

Perc Cholecystostomy

Agree with Venty. Get your best IR person on board. You're probably still gonna have to do the case eventually, but it'd be preferable for him not to be septic / near-shocky when you do so.

Goals of care discussion needs to be had. It is entirely reasonable to expect he'll die in the hospital no matter what we do. Family and patient need to understand this. It is also reasonable for some to expect him to survive to discharge, but it's not gonna be a "little bump in the road" or just a "brief setback" like family and surgeon might want or hope it to be.

 

[Bostonredsox]

Pre induction art. Glidescope for airway and may need smaller tube. Treat case like a heart with low ef with PAC and milrinone. Family needs to understand he may be on blower for a long time and trached again.

Guy is in septic shock from GB, cr is only 1.5 now but he may be inline for some significant kidney hypo perfusion as he will likely be given less volume than he needs given people being leary with that EF, plus the general hypo perfusion of end organs in severe sepsis +/- shock..THUS.. I would think the exclusively renally cleared milrinone would be substituted for dobutamine if in fact he was not maintaining an ScvO2 in the 70s and required an ionotrope.

To the OP, have been apart of 2-3 of these. They all got EGDT and their source control was a perc drain. 1 survived relatively long term and eventually got an LC. With that list of co-morbids he is likely to do very poor regardless of what you do.

 

[cincincyreds]

Tough case. Our M and Ms usually start with a H and P like this.

As people said, secure the airway safely, plan for postopmechanical ventilation. Might need a swan for pressor and fluid management. A line obviously. And as it was said, a long discussion with the family about what to realistically expect.

Sounds like the patient should have been intubated a little while before you met them.

 

[sluggs]

Guy is in septic shock from GB, cr is only 1.5 now but he may be inline for some significant kidney hypo perfusion as he will likely be given less volume than he needs given people being leary with that EF, plus the general hypo perfusion of end organs in severe sepsis +/- shock..THUS.. I would think the exclusively renally cleared milrinone would be substituted for dobutamine if in fact he was not maintaining an ScvO2 in the 70s and required an ionotrope.

To the OP, have been apart of 2-3 of these. They all got EGDT and their source control was a perc drain. 1 survived relatively long term and eventually got an LC. With that list of co-morbids he is likely to do very poor regardless of what you do.

Curious about using milrinone over dobutamine. Milrnone has a longer half life, and can have more profound vasodilatory effects which can be a problem in sepsis?
Why would you favor it here? Just curious?

 

[VentdependenT]

my guess would be for pulm artery vasodilatory effect. if i needed pressor would be levophed (leave-em-dead).

new 2nd line pressor for septic shock is epi btw

 

[nap$ter]

sounds like a veteran - propofol, vec, tube.

 

[Globulinus]

Septic, comorbidities - sick like a dog; potentially crappy airway; needs to be done NOW...no ET, central line, ect..
VA style tango
Preop: - bronchodilators;a/biotics; adult IV; Aline; pressors(God given - Epi,Levo) drawn up and ready. Dob available. Glyde , FOB in room. Family&patient discussion about prognosis of "going to sleep and have a tube again "
pray.... Gonna tank on induction if not careful - Keto;Thio; Etom. or (prop+neo). RSI.
tls/mac/cordis after asleep.
septic shock management in addition to usual anesthetic.
waking up -- hard to tell...

milrinone - no, no: takes long time to kick in, even longer to get out, +sepsis... =>Levo, then Epi. Dob possible but not desired here(hx of AFib/rvr ?, pacer. FLO or nitric for pHTN if necessary...
tough case.

 

[dhb]

Priest, pine wood, earth sprinkle

 

[G0S2]

Septic, comorbidities - sick like a dog; potentially crappy airway; needs to be done NOW...no ET, central line, ect..
VA style tango
Preop: - bronchodilators;a/biotics; adult IV; Aline; pressors(God given - Epi,Levo) drawn up and ready. Dob available. Glyde , FOB in room. Family&patient discussion about prognosis of "going to sleep and have a tube again "
pray.... Gonna tank on induction if not careful - Keto;Thio; Etom. or (prop+neo). RSI.
tls/mac/cordis after asleep.
septic shock management in addition to usual anesthetic.
waking up -- hard to tell...

milrinone - no, no: takes long time to kick in, even longer to get out, +sepsis... =>Levo, then Epi. Dob possible but not desired here(hx of AFib/rvr ?, pacer. FLO or nitric for pHTN if necessary...
tough case.

Nope. Would use milrinone.


Am Heart J. 2001 Feb;141(2):266-73.
Pharmacodynamic effects of milrinone with and without a bolus loading infusion.
Baruch L, Patacsil P, Hameed A, Pina I, Loh E.
Source
Bronx Veterans Affairs Medical Center, Bronx, NY, USA

No time with bolus and 30 mins w/o.

Milrinone plus levo is how I would go.

 

[gtb]

Priest, pine wood, earth sprinkle

Very poetic.

 

[VentdependenT]

orders should include:

VP (Vulture Precautions)
PBABS (pine box at bed side)

 

[Globulinus]

Nope. Would use milrinone.


Am Heart J. 2001 Feb;141(2):266-73.
Pharmacodynamic effects of milrinone with and without a bolus loading infusion.
Baruch L, Patacsil P, Hameed A, Pina I, Loh E.
Source
Bronx Veterans Affairs Medical Center, Bronx, NY, USA

No time with bolus and 30 mins w/o.

Milrinone plus levo is how I would go.

Sure, there are 1000 ways to skin the cat

my take on it: Dude has sepsis, bad lungs and bad lungs. kidneys gonna be bad very soon..
1st - treat sepsis. Fresh baked here supportive therapy for everything else.
milrinone poor choice in sepsis...
Benefits? can't come up with one

 

[bkell101]

Home 2L / cxr without new changes...now with poor sats on more oxygen than he normally requires...this is suspicious...why the worse than normal hypoxia? Related to the sepsis somehow or second undetected pathology also going on?

 

[bkell101]

Venty thank you for pointing out eppy now second line choice in sepsis... I don't think many people have adopted this......


Vaso though I think I read has some pulm vaso dilating properties...if true, would it be beneficial in a subset of patients : septic shock + pa htn?

 

[bkell101]

Just an intern but might as well start somewhere....

Before going to sleep....

Address the hypoxia....turn up the nc or change oxygen deliver method to get sats to 90...wonder if it'll get there....

Listen to his lungs for wheezing....role for bronchodilators if so

Septic patient equals needs volume ...how much has he gotten so far? I guess they aren't running early goal directed therapy with that 20 g unless they are using the non invasive approach using ivc us....which is what I would do...throw the probe over his belly to see if ivc is collapsing over 50 percent...if so start bolus ivf .....then get some central access

Aline for the case ......likely will need pressors titrated also helpful to check pH (copd + pathology creating metabolic acidosis may be tricky to manage?

 

[bkell101]

Airway....

Prior records available? History of difficult intubation? History of snoring ?(bet he has some osa too) He looks like he may be difficult with being short and fat + prior trach. ...

If all signs are pointing difficult intubation I would favor awake foi....

Already hypoxic + poor reserve (severe copd/obese) + poor view/difficult airway --> sounds like pt has high likelyhood of desaturation ....which creates Hpv on top of already high pa pressures ---> obstructive shock (probably easy to create in a weak heart now with likely more weakening from the sepsis).....

Really makes me favor awake foi

 

[Agast]

I'd be tempted to give him a unit of PRBCs for volume resuscitation during the inevitable tanking post-induction. Might improve his hypoxia.

 

[bkell101]

If I didn't do awake foi.....patient not agreeable? ....

Let my colleague know to be available b/c possibly difficult airway
Good preparation: airway adjuncts / pressors drawn up

Pre-oxygenate pre oxygenate pre oxygenate (he may not come up to over 94 percent)

Position well

Pre induction: something that blunts airway reactivity? Lidocaine / fentanyl?

Induction agent: propofol in this already vaso dilated and cardiac depressed pt probably tanks him? Etomidate debatable in sepsis? Makes ketamine or fentanyl/versed combo my guess

Sux

Glides cope

History trach - maybe smaller tube

Through the process:
Avoid bronchospasm
Avoid exacerbation of pa htn (ie hypoxia)
Avoid further drop in bp
Mindful that acute inc in bp and hr could worsen aortic regurge?

 

[45408]

Perc Cholecystostomy

Agree with Venty. Get your best IR person on board.

Perc tubes are usually a chip shot. You hardly need the "best IR person." It's rarely technically impossible for them (unless the GB is packed with stones), but if the pt has a necrotic or emphysematous gallbladder, then a perc tube isn't gonna solve your problem at all. If anything, the tube/wire might put a hole in it even faster than it would have already.

but it's not gonna be a "little bump in the road" or just a "brief setback" like family and surgeon might want or hope it to be.

You are preaching to the choir. I've watched two of these guys die in the SICU afterwards after a day or three of full-court press. It's the MICU guys that always try to act like this will be no big deal as they try to sell it to us. No way, Jose...

 

[VentdependenT]

Perc tubes are usually a chip shot. You hardly need the "best IR person." It's rarely technically impossible for them (unless the GB is packed with stones), but if the pt has a necrotic or emphysematous gallbladder, then a perc tube isn't gonna solve your problem at all. If anything, the tube/wire might put a hole in it even faster than it would have already.


You are preaching to the choir. I've watched two of these guys die in the SICU afterwards after a day or three of full-court press. It's the MICU guys that always try to act like this will be no big deal as they try to sell it to us. No way, Jose...

Micu selling you what? Calculate this guys apache, he is TOAST.

I dont know what fookin surgeon does a laproscopic surgery to get out a "necrotic" gallbladder. Itll be falling apart and adherent to everything. its gotta be open.

The perc-chole was MADE for this guy. If surgeon says thats not an option in a pt with severe sepsis (possible shock as well), crap heart, crap lungs, then go to OR, dump in 2L (before induction) start levophed, and dont bother extubating. swan pointless. cordis overkill. get in and get out so you dont have an intraop death. Hook up a flotrac post op. cvp if it makes you feel better...yes to aline, yes to defib pads.

 

[bkell101]

Intra op --

Sevo as agent (avoiding des with irritation in copd) ...avoid nitrous? (Blebs/pneumothorax risk?)
Use opiates to reduce decrease amount of inhalation anesthetic decreasing myocardial function
(An above poster mentioned treat like cardiac case with low ef, what is the strategy employed?)

Treat the sepsis and hypotension:
fluids (guided by PA cath vs tee probe?) ...I'm thinking cvp to 10-12 in a guy with severe pa htn could lead to under filling of the tank as this could be artificially high
If map still not 65 use Levo...vaso/epi depending on the hr
Check scvo2 ... <70....prbcs for hct <30 ...then dobutamine (mindful of his afib history)

Manage the vent:
Use some peep 5 or so to avoid atelectasis/shunting (he's obese and having and surgery)
Avoid excessively high peak pressures as this guy probably has Swiss cheese lungs and h/o maybe pneumothorax
Avoid air trapping with increased e times and avoiding high rr (his copd lends itself to dynamic airway collapse)

 

[fakin' the funk]

You are preaching to the choir. I've watched two of these guys die in the SICU afterwards after a day or three of full-court press. It's the MICU guys that always try to act like this will be no big deal as they try to sell it to us. No way, Jose...

Hallelujah!

That's because they see disasters like these. When they die, they blame the patient.

We don't see disasters like these as often. When they die, we blame ourselves.

 

[45408]

The perc-chole was MADE for this guy.

For the sake of a case discussion, I'm assuming the surgeon would have thought of that, because he doesn't intentionally trash his 30-day mortality rate. The perc chole tube works when you have an intact gall bladder with an obstructed outflow tract. When the GB itself is rotting away and is/will be perforated, a PC isn't going to do a damn thing.

And I've seen a successful lap chole for a gangrenous GB.

 

[Bostonredsox]

Curious about using milrinone over dobutamine. Milrnone has a longer half life, and can have more profound vasodilatory effects which can be a problem in sepsis?
Why would you favor it here? Just curious?

I was not favoring it, I was discouraging it. i would use dobutamine/levophed. This guy is or will be in shock and his GFR will be in the single digits. Milrinone is 100% renally excreted and has a long t1/2....so it will last forever in this guy. I would use the shorter acting more renal failure friendly dobutamine as my ionotrope and levo/vasopressin for my pressors. Aline/CVC/Swan/Vent. None of it will matter. Though I live for patients like this as they are the challenge that gets me to do this job....as vent said....his apache II is >30. That is not compatible with life.

 

[OB1🤙]

I would shine this turd as follows:

Pre-Preinduction:
1)Come to Jesus talk with all parties.

Preinduction:
1) Due diligence as far as ICD/pacer settings.
2) Awake aline with a Flotrac. Let's see what our cardiac output is.
3) Awake central line (and I just about never do this).
4) Put on a TTE probe and look at the heart myself. Assess volume status/filling.
5) Play a fun little dose-finding game, figuring out what drugs improve the hemodynamics. I'd probably start with splashes of levo and epi and see what happened. Vaso would probably find its way into the mix too. Once I find drugs/doses that I like, I'd proceed with

Induction:
1) Do it gentle. I'd probably use a splash of ketamine with a squirt of propofol, because that's how I roll. Do it however you like, so long as it's gentle.
2) Airway management depends. Assuming his bony anatomy is normal, I'd probably just paralyze and Glidescope the guy, with a smaller tube around prn.
3) Since central line already in, pressor/inotrope management is made easier when (not if) he crumps after induction/PPV.

Intraop:
1) Encourage the least amount of dicking around possible. Source control is the goal- accomplish it quick. If you have to open, open.

Postop:
1) Play by ear. I'm generally aggressive about trying to extubate this kind of guy if it's at all feasible, because I hate seeing the unit play games with marginal ABGs and waiting and waiting for perfect numbers which aren't gonna come.
2) Possibly extubate to BiPAP prn.
3) Enjoy a peaty glass of Laphroaig.

 

[excalibur]

Outstanding responses and wonderful discussion.

Let me state a few things before I describe what happened with the case. First I totally forgot to mention that part of the reason for the patient's prolonged mechanical ventilation was that 2 weeks after his CABG/AVR while he was recovering with a trach in an LTAC facility, the patient had a perfed bowel and required colectomy/colostomy with ICU admission and mechanical ventilation. Upon improving from the bowel perf, the pt developed an empyema and this is main reason he was in ICU for months.

Next is how I got this case. I finished a cysto, which was last case in my room. It is mid morning, and I just go to the board, because actually it might be time for me to head to the house. I see I have been assigned a lap chole on an inpt. No biggie I think...should be done quickly. I pop into the lounge and I see my partner, who is the board runner, and he gives me the scoop. He tells me patient is in the inpatient holding area and the OR crew is ready to go. I tell you this because for all you residents/med students out there, this is what it is like sometimes when you are on your own in private practice. You drop your last patient in PACU, you come to the board, you discover a complex case on a difficult patient in a different OR, and everyone is ready to go.

YOU BETTER BE READY TO THINK FAST AND ACT FASTER IN PRIVATE PRACTICE!!!

After hearing the story from my partner in the lounge, I mentioned art line and central line, and he stated he already informed the techs to prepare that. I also informed them of a blood warmer. Next up I knew the pt had AICD, and EMI could present a problem. I enter OR to get things ready before seeing the patient. I inform the OR nurse that patient is quite sick and I want defib pads on patient, so she brings the cart to OR. Our Medtronic rep was in house doing a pacemaker, so I go over my plan with him. I simply wanted a magnet over AICD to deactivate defibrillation function so AICD would not sense EMI as Vfib. I mentioned I wanted pads on too. He said yes, the magnet would knock out sensing for defib function and would not affect pacing function. He said pads are really not needed as if you sense the pt is in Vfib you take off magnet and AICD would defibrillate. I said I would feel safer with pads on as back up in case AICD malfunctions for some reason.

Get an Alaris pump for pressors. Get some sticks of phenylephrines and Levophed drip. Also NTG drip in case pressures are out of control.

Go see patient. Frank discussion with patient and family. Postop mechanical ventilation discussed.

To OR. ASA monitors. Magnet on AICD. Defib pads on. Pre-induction A-line. Can't get it by palpating pulse. I use ultrasound and get it. Preoxygenation. RSI with etomidate. I did not feel I would have a problem with DL, and I thought I would need a smaller tube, but I did not expect the following, and I probably should have. Mac 3, Gr I. 7.0 ETT with stylet will not pass. 6.0 ETT no stylet will not pass (The stylets in the room won't fit smaller tubes--you would need stylets in our pedi cart). 5.0 ETT no stylet will not pass. Ventilation with oral airway was easy and never a problem. Turn up some agent during mask ventilation and having discussion with my partner and the surgeon. We discuss other therapeutic interventions for septic gallbladder, waking pt up, trach. After discussions I call for Glidescope. Felt I would have a clearer view and maybe I could see if I would have better luck. The glottis is clearly small on GS. I stylet a 5.0 ETT and SQUEEZE a 5.0 ETT in there. Yep. A size 5.0 ETT. +ETCO2. We are ventilating OK. High peak pressures of 35-36 but not outrageous. The last cm demarcation on a 5.0 ETT is 23 cm. So essentially the ETT connector piece is just off his lips.

We elect to proceed. His BP after induction was very stable. Stayed 90's over 60's. USG R IJ central line. No swan. No TEE. Starting CVP of 25.

I thought of my friend Hawaiian Bruin...

KeepItSimpleStupid

Simple: Maintain paralysis, light anesthesia, aggressive fluid resuscitation, replace blood if hemorrhaging, keep him intubated, pain control. I have Levophed if needed. Simple.

That's exactly what I did.

Kept him at 0.6-0.7 ET% of iso. As others stated, I gave fluid resusciation in the setting of sepsis despite h/o CHF. 2 liters of fluid in before incision. Pressure increased slightly during incsion/dissection like 115-120 SBP. More fentanyl. During laparoscopy they had trouble with visualization due to bleeding. Decision made to convert to open chole. Bleeding picks up, and I request blood for transfusion. SBP came back down to 90 mm Hg. I start transfusing and bleeding still not under control. Canisters keep filling up, and I keep giving. Total blood loss was 1500 mL and I gave 4 units. BP was stable during whole time. I also gave a gram of calcium. No pressors. Maybe a couple of mini boluses of phenylephrine during bleeding.

Surgery done, and we keep him intubated and take him to ICU.

Next day pt is awake, breathing on own at regular rate. His ABG's are back to his crappy normal. Decision made to extubate with gen surg and CT surg in room with trach kit available. Pt did well on extubation and back to his baseline breathing, which isn't that good, but normal for him.

Oh. After reading these posts, I asked the general surgeon about possibility of percutaneous cholecystostomies and if they are done at my small county hospital. He said they can be done, but he mentioned that for septic gallbladders, he finds that perc cholecystostomies are just a temporizing measure. I believe someone above stated something similar.

 

[VentdependenT]

well played.

 

[pgg]

Very nice. Thanks for posting the case.


An obese respiratory cripple going tubed to the ICU with a 5.0 ETT makes me all puckery. Good thing he got extubated soon.

 

[PonyUp]

What would you have done if he wasn't tolerating the 5.0?

 

[excalibur]

What would you have done if he wasn't tolerating the 5.0?

Well if we can't mechanically ventilate efficiently and/or safely, we can't do case.

I would possibly see if we could go one half to one size up on GS. There was discussion about waking pt up and possible awake re-do trach = another nightmare

 

[45408]

2 weeks after his CABG/AVR while he was recovering with a trach in an LTAC facility, the patient had a perfed bowel and required colectomy/colostomy with ICU admission and mechanical ventilation. Upon improving from the bowel perf, the pt developed an empyema and this is main reason he was in ICU for months.

The CABG+subsequent colectomy (C&C special) is a nasty mix. Those patients almost always do poorly or die.

I see I have been assigned a lap chole on an inpt. No biggie I think...should be done quickly.

Ah yes, it's like when the ED calls and says they've got an appy for you. I envision a 20-something with a BMI of 22, and it's an 87-year old with a host of comorbidities.

Great case. Thanks for posting - it's interesting for me to see the anesthesia side of things.

 

[OB1🤙]

Great case, man.

One thing that occurs to me- I want to know why this guy has AR with a new valve in. If he has a known paravalvular leak from the initial surgery, that's well and good. But if he has a vege sitting on his valve causing new AR- this is profound badness.

It's probably completely unrelated, but if nobody has seen this leak before this admission, it's concerning.

 

[dhb]

Good case, good management i wonder if he'll make it out of the hospital though.

 

[redy]

Surprised he was able to be extubated so soon.

Sent from my SPH-L710 using Tapatalk 2

 

[excalibur]

Great case, man.

One thing that occurs to me- I want to know why this guy has AR with a new valve in. If he has a known paravalvular leak from the initial surgery, that's well and good. But if he has a vege sitting on his valve causing new AR- this is profound badness.

It's probably completely unrelated, but if nobody has seen this leak before this admission, it's concerning.

Good pickup, HB. I reread the Echo, and it was my mistake. Moderate MR but no significant aortic insufficiency per the Echo. My apologies