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.
