Oral Board Grab Bag Thread

[Robert Loblaw]

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Take a penny give a penny (post a response, post a question--be concise). I'll start:

34 y/o G4P2 at term is brought to the OR for c/s. She is 62" and 342 pounds. She has placenta percreta. Anesthetic plan, monitors? A colleague suggest you use cell saver--is this a good idea?

 

[cincincyreds]

Take a penny give a penny (post a response, post a question--be concise). I'll start:

34 y/o G4P2 at term is brought to the OR for c/s. She is 62" and 342 pounds. She has placenta percreta. Anesthetic plan, monitors? A colleague suggest you use cell saver--is this a good idea?

Assuming there is no fetal distress and assuming the patient is a candidate for an epidural, I would place an epidural for postop pain control. Then, assuming a normal airway, I would preoxygenate the patient with 100% O2, and with cricoid pressure place a 6.0 ETT using half a mac of Sevo and half a mac of N20 for maintenace in order to decrease the risk of uterine atony that could also increase the risk of bleeding. I would then place a postinduction arterial line for blood draws and beat to beat monitoring. I would make sure to have either two large bore IVs or a cordis.

As far as a cell saver, I believe there would be no contrainduction.

 

[PMPMD]

Assuming there is no fetal distress and assuming the patient is a candidate for an epidural, I would place an epidural for postop pain control. Then, assuming a normal airway, I would preoxygenate the patient with 100% O2, and with cricoid pressure place a 6.0 ETT using half a mac of Sevo and half a mac of N20 for maintenace in order to decrease the risk of uterine atony that could also increase the risk of bleeding. I would then place a postinduction arterial line for blood draws and beat to beat monitoring. I would make sure to have either two large bore IVs or a cordis.

As far as a cell saver, I believe there would be no contrainduction.

There are theoretical risks but it appears the clinical significance of these is uncertain.

Catling S, Thomas D. Intraoperative autologous blood transfusion. In: Lynch CB, Keith L, Lalonde A, Karoshi M, editors. A textbook of postpartum haemorrhage. Duncow: Sapiens Publishing; 2006. p. 421-6.

SAFETY OF CELL SALVAGE IN OBSTETRICS

Two theoretical problems attend the use of cell salvage at the time of Cesarean section. First, in a Rh-negative mother, there is a risk of Rh immunization if the fetus is Rh-positive. As the cell saver cannot distinguish fetal from adult red cells, any fetal red cells suctioned from the operative field will be processed and re-infused with the maternal red cells. In practice, studies show that the degree of contamination with fetal red cells during cell salvage at Cesarean section is between 1 and 19 ml 11–13 . Applying the standard Kleihauer calculation, this would require between 500 and 2500 units (1–5 ampules) of Anti-D to avoid Rh immunization. As all Rh-negative patients require Anti-D after Cesarean section, patients receiving salvaged blood may simply require an increased dose. The second theoretical problem is contamination with amniotic fluid, raising the specter of iatrogenic amniotic fluid embolus (AFE). This theoretical complication has been investigated by several workers, and has not been found to be a problem in practice 12–16. The difficulty is that the precise elements of amniotic fluid, which cause the rare, and unpredictable ‘anaphylactoid syndrome of pregnancy’ (as AFE is more correctly called), remain unknown. To conduct a prospective, randomized, controlled trial with an 80% power to demonstrate that cell salvage does not increase the incidence of AFE by five-fold would require up to 275 000 patients, a number so enormous that the effort is unlikely ever to be undertaken. To demonstrate the absolute safety of a technique without randomized, controlled trials requires careful clinical audit of a large number of cases, supported by robust in vitro evidence.

 

[drccw]

I remember on my oral boards I got a lot of

"suggestions from a colleague...."


drccw

 

[BlackTalon]

Take a penny give a penny (post a response, post a question--be concise). I'll start:

34 y/o G4P2 at term is brought to the OR for c/s. She is 62" and 342 pounds. She has placenta percreta. Anesthetic plan, monitors? A colleague suggest you use cell saver--is this a good idea?

I'm just a 3rd year medical student, but I'll take a whack at it.

Placenta percreta = invasion of placenta out of uterus into surrounding organs.
Main concern = deliver baby safely + massive hemorrhage.

Work-up: (assuming no other history of note)
1. determine extent of percreta with MRI (if there is time)
2. full set of bloods, coag studies, cross-match, etc. and optimize as far as possible
3. ensure sufficient help present. Senior surgeon, anesthetists, OR team.
4. activate massive transfusion protocol, which in my centre includes loads of PCT and bld products on standby, equipment such as warmers, infusers, etc.
(since I get the impression patient is getting the c/s soon, insufficient time for autologous blood donation)
5. obtain cell saver
6. KIV prophylactic embolisation catheter/balloons in iliac arteries
7. KIV obtain recombinant FVII (use as last resort)

Anaesthetic plan:
1. Standard monitors + arterial line + central line
2. insert two large bore peripheral IV
3. ensure vasopressors and 4xPCT on hand in infusers, ready to go.
4. RSI with prop - sux - tube, minimize opioids, maintain on inhalationals.
5. maintain BP on lowish side of normal with blood + vasopressors + fluids
6. once baby out, use uterotonics (ergometrine?) to reduce blood loss
7. pray pray pray.

Ok, I'll accept my bashing now.... 😉

Question: 30yo male caucasian patient, hx of paralysis L3 and below due to gunshot wound to spine (hunting accident) 1 year ago. No other medical hx of note. Now comes in with massive internal bleeding into fractured pelvis from RTA. Rest of body fine, airway assessment fair. Surgeon wants to go in now. Would you RSI this patient, and how would you do it?

 

[Robert Loblaw]

I'm just a 3rd year medical student, but I'll take a whack at it.

Placenta percreta = invasion of placenta out of uterus into surrounding organs.
Main concern = deliver baby safely + massive hemorrhage.

Work-up: (assuming no other history of note)
1. determine extent of percreta with MRI (if there is time)
2. full set of bloods, coag studies, cross-match, etc. and optimize as far as possible
3. ensure sufficient help present. Senior surgeon, anesthetists, OR team.
4. activate massive transfusion protocol, which in my centre includes loads of PCT and bld products on standby, equipment such as warmers, infusers, etc.
(since I get the impression patient is getting the c/s soon, insufficient time for autologous blood donation)
5. obtain cell saver
6. KIV prophylactic embolisation catheter/balloons in iliac arteries
7. KIV obtain recombinant FVII (use as last resort)

Anaesthetic plan:
1. Standard monitors + arterial line + central line
2. insert two large bore peripheral IV
3. ensure vasopressors and 4xPCT on hand in infusers, ready to go.
4. RSI with prop - sux - tube, minimize opioids, maintain on inhalationals.
5. maintain BP on lowish side of normal with blood + vasopressors + fluids
6. once baby out, use uterotonics (ergometrine?) to reduce blood loss
7. pray pray pray.

Ok, I'll accept my bashing now.... 😉

Question: 30yo male caucasian patient, hx of paralysis L3 and below due to gunshot wound to spine (hunting accident) 1 year ago. No other medical hx of note. Now comes in with massive internal bleeding into fractured pelvis from RTA. Rest of body fine, airway assessment fair. Surgeon wants to go in now. Would you RSI this patient, and how would you do it?

Your answers are fine if not concise ;-)

Avoid sux given paraplegia. Assuming normal airway anatomy with low risk of failed intubation and c-spine cleared--etomidate/roc/tube. RSI w inline stabilization if not cleared.

Q: Your 70kg patient complains of circumoral numbness and tinnitus moments after you injected 40 ml of 0.5% bupivicaine for ISB. What is your plan for management? If you injected lidocaine instead of bupiv would your plan be any different?

 

[diceksox]

5'2", 342 lbs = BMI of 63 + pregnant. I know that seems like every OB patient but given that you'd probably need two assistants to get the breasts away from the neck to even think about cricoid she'd have to have a Mallampati zero for me not to say fiberoptic.

As an aside does anyone know if dexmedetomidine is effective in someone taking phentolamine?

 

[pgg]

I would suggest that anyone reading this thread as part of their oral board prep actually speak out loud their answers before typing up a reply.

It's easy to sound good in writing, but if you don't practice speaking answers, when the real thing comes you'll trip over words and sound disorganized, even if you know exactly what to do and how to do it.

Close the door and make the words with your lips.

Lists like BlackTalon's are great for written exam prep and message board discussion, but lists are not a spoken answer.

I remember on my oral boards I got a lot of

"suggestions from a colleague...."

So did I, most of them of dubious value.

Don't let oral examiners talk you into anything. If you're struggling, sometimes they'll throw a hint out or prod you in the right direction, but treat their helpful colleague suggestions as if they came from a PACU nurse. 🙂 Ie, not always wrong, but deserving of very healthy skepticism.

 

[PinchandBurn]

Your answers are fine if not concise ;-)

Avoid sux given paraplegia. Assuming normal airway anatomy with low risk of failed intubation and c-spine cleared--etomidate/roc/tube. RSI w inline stabilization if not cleared.

Q: Your 70kg patient complains of circumoral numbness and tinnitus moments after you injected 40 ml of 0.5% bupivicaine for ISB. What is your plan for management? If you injected lidocaine instead of bupiv would your plan be any different?

I would optimize oxygenation and ventilation by placing a FM and O2. I would consider hyperventilating the patient to decrease blood flow to the brain. I would give midaz and look at the EKG and other vitals. If patient goes into an arrthymia or becomes unstable, I would consider intubation, consider starting CPR and consider intralipid therapy.

Q: 70 yo patient with an AICD comes in for a lap chole. Aneshtetic implications? Should the device be disarmed? Why/why not? Should sux be avoided? If so, why? How will you proceed? Rationale?

 

[somedumbDO]

I would optimize oxygenation and ventilation by placing a FM and O2. I would consider hyperventilating the patient to decrease blood flow to the brain. I would give midaz and look at the EKG and other vitals. If patient goes into an arrthymia or becomes unstable, I would consider intubation, consider starting CPR and consider intralipid therapy.

Q: 70 yo patient with an AICD comes in for a lap chole. Aneshtetic implications? Should the device be disarmed? Why/why not? Should sux be avoided? If so, why? How will you proceed? Rationale?

but that can decrease your seizure threshold tho...

 

[PinchandBurn]

but that can decrease your seizure threshold tho...

it increases the sz threshold (less perfusion to the brain).

 

[Robert Loblaw]

I would optimize oxygenation and ventilation by placing a FM and O2. I would consider hyperventilating the patient to decrease blood flow to the brain. I would give midaz and look at the EKG and other vitals. If patient goes into an arrthymia or becomes unstable, I would consider intubation, consider starting CPR and consider intralipid therapy.

Q: 70 yo patient with an AICD comes in for a lap chole. Aneshtetic implications? Should the device be disarmed? Why/why not? Should sux be avoided? If so, why? How will you proceed? Rationale?

I'm not sure if you are taking the exam or not, but I would just pass on a piece of feedback that I got in my mock orals from our board examiners which was to consider not saying "consider." I was asked more than once if I would consider something or do something. Just a stylistic point.

The point I was making about lidocaine versus bupivicaine was that simply I would have a lower threshold for starting intralipid in someone who recieved bupivicaine because it has a lower CNS/CV toxicity ratio and one may see cardiovascular symptoms prior to CNS symptoms. I think the ratio is like 7 for lidocaine and 2'ish for bupivicaine.

To your question:

AICD: I would want to know both what type of device it is (manufacturer) as well as the indication for placement. Presence of the device is suggestive of significant cardiovascular disease and I would want to illicit the history of placement and adjust my anesthetic plan accordingly. WRT to the device itself, I would want to know if it has fired recently or at all, whether there is an anti-tachyarrythmia or pacing functions. WRT to operative plan, I would expect the possibility of EMI given the use of cautery and the proximity to the heart. to reduce the likilihood of emi i would position return pad on the LE and recommend shurt bursts of bipolar (if possible) cautery. I would have a magnet available for placement but would not place it unless significant EMI occured.

Sux can raise the potassium which could theoretically affect device capture (or even precipitate arrhythmia), but in the absence of any hx that would raise suspicion for precipitious K response to sux and no other CI, I would use succyncholine without additional concern over another patient without an AICD.

 

[Robert Loblaw]

Q: A patient present for his first session of ECT. Other than MDD, he is 58 y/o healthy, BMI 25, no allergies. What is your anesthetic plan? What, if any, hemodynamic derrangements would you prepare for? How would your plan change if he had a 4.1 cm ascending aortic aneurysm?

 

[cchoukal]

it increases the sz threshold (less perfusion to the brain).

The conventional wisdom is that hyperventilation makes a seizure MORE likely (there's some literature on this in the ECT world). If a seizure were to occur during hyperventilation, you'd have decreased oxygen delivery to the brain during a time of dramatically heightened oxygen consumption (during the seizure).

 

[maceo2]

Take a penny give a penny (post a response, post a question--be concise). I'll start:

34 y/o G4P2 at term is brought to the OR for c/s. She is 62" and 342 pounds. She has placenta percreta. Anesthetic plan, monitors? A colleague suggest you use cell saver--is this a good idea?

this grab bag question is TOO easy. not a very good one.. throw in jehovahs witness and now you got something but even then not hard

 

[Robert Loblaw]

this grab bag question is TOO easy. not a very good one.. throw in jehovahs witness and now you got something but even then not hard

Post a harder one then 🙂. Fine she's JH, MH and has MS, MS, MR, MR with an IABP, TIPS, and VPS for NPH. She refuses regional...and general.

It's not so much about difficulty but hitting as many topics as possible here so that gaps in knowledge or understanding are identified. Plus I wanted to remind people that cell saver has been successfully used without untoward r/o AFI or hemolytic t'fusion reaction.

 

[Lee123]

Don't let oral examiners talk you into anything. If you're struggling, sometimes they'll throw a hint out or prod you in the right direction, but treat their helpful colleague suggestions as if they came from a PACU nurse. 🙂 Ie, not always wrong, but deserving of very healthy skepticism.

Correct. Think in terms of the real world: sometimes you get a correct suggestion; sometimes it is incorrect. I also agree that you don't "consider", but do it. When you have a case, how long do you "consider" doing something? if you just "considered" nothing would get done. Commit to an action.

Here is a case I just did a few days ago:

76 year old for a biliary diversion in interventional radiology. 4 foot 9", 40kg, malnourished and jaundiced secondary to pancreatic CA, which is why she is having the procedure. She is nauseated and unable to eat. There is an anterior mediastinal mass seen on CT just at the level of the carina. There is no compression. There is no tracheal deviation.

BP 90/40. HR 95.
Hb 10.5 g/dL
Albumin 2.5
K 4.9 meq/dL

Airway: 1.5 FB from chin to hyoid. No teeth. good mouth opening. Uvuala seen.


Radiologists says this will most likely be difficult and long. As a side note, there is a national shortage of Etomidate, so there is none in the hospital.

 

[Arch Guillotti]

Assuming there is no fetal distress and assuming the patient is a candidate for an epidural, I would place an epidural for postop pain control.

Where are you going to place the epidural? Lumbar or thoracic?

 

[Arch Guillotti]

I'm just a 3rd year medical student, but I'll take a whack at it.

Placenta percreta = invasion of placenta out of uterus into surrounding organs.
Main concern = deliver baby safely + massive hemorrhage.

Work-up: (assuming no other history of note)
1. determine extent of percreta with MRI (if there is time)
2. full set of bloods, coag studies, cross-match, etc. and optimize as far as possible
3. ensure sufficient help present. Senior surgeon, anesthetists, OR team.
4. activate massive transfusion protocol, which in my centre includes loads of PCT and bld products on standby, equipment such as warmers, infusers, etc.
(since I get the impression patient is getting the c/s soon, insufficient time for autologous blood donation)
5. obtain cell saver
6. KIV prophylactic embolisation catheter/balloons in iliac arteries
7. KIV obtain recombinant FVII (use as last resort)

Anaesthetic plan:
1. Standard monitors + arterial line + central line
2. insert two large bore peripheral IV
3. ensure vasopressors and 4xPCT on hand in infusers, ready to go.
4. RSI with prop - sux - tube, minimize opioids, maintain on inhalationals.
5. maintain BP on lowish side of normal with blood + vasopressors + fluids
6. once baby out, use uterotonics (ergometrine?) to reduce blood loss
7. pray pray pray.

Ok, I'll accept my bashing now.... 😉

pretty good answer.

A few comments:
MRI is helpful and hopefully she would have one but imaging is never perfect in this type of situation and you never know for sure until there is surgical exposure.

I wouldn't get coags unless there is a reason to.

Catheters and balloons are possible but can be a logistical challenge in a normal OR. Plus you have to coordinate with IR. My guess would be that IR would laugh at you if there wasn't a plan beforehand.

If large bore peripheral access is obtained then I probably wouldn't bother with a central line but you can't go wrong with a cordis if that's what you decide to put in.

 

[BlackTalon]

pretty good answer.

A few comments:
MRI is helpful and hopefully she would have one but imaging is never perfect in this type of situation and you never know for sure until there is surgical exposure.

I wouldn't get coags unless there is a reason to.

Catheters and balloons are possible but can be a logistical challenge in a normal OR. Plus you have to coordinate with IR. My guess would be that IR would laugh at you if there wasn't a plan beforehand.

If large bore peripheral access is obtained then I probably wouldn't bother with a central line but you can't go wrong with a cordis if that's what you decide to put in.

Thank you! 😀

Good point about coags and the central line. I probably wouldn't need either of them. BTW, I had to google "cordis"... showing my limited knowledge here 😳

In real life, I probably wouldn't go through with IR, but it's something I would like to have if the extent of percreta is significant.

And as diceksox noted, I missed the BMI of the patient totally!

 

[cincincyreds]

Where are you going to place the epidural? Lumbar or thoracic?

Lumber as the incision for a c-section is about t12-l1 dermatome

 

[Arch Guillotti]

Lumber as the incision for a c-section is about t12-l1 dermatome

Right, I guess what I was sort of getting at was that since the patient has a percreta then the incision might be vertical and a lot larger than a normal c/s incision. I am not sure if a lumbar epidural would cover it in this case.

 

[DO4lifer]

Lumber as the incision for a c-section is about t12-l1 dermatome

Because of her size, its unlikely a lumbar epidural would be useful because the horizontal incision will be much higher. Because of all the pannus, it will be a high incision needing a thoracic epidural for sufficient post op pain control (T9-10).

Massive transfusion protocol is reserved for hemorrhaging trauma patient that rolls into the OR. If you have time to send for labs, then send for cross-match (10 units or whatever). No need to for unnecessary transfusion reactions.

 

[DO4lifer]

Q: Your 70kg patient complains of circumoral numbness and tinnitus moments after you injected 40 ml of 0.5% bupivicaine for ISB. What is your plan for management? If you injected lidocaine instead of bupiv would your plan be any different?

1. shoot myself for injecting essentially upper limit of toxic doses of bupiv in one swing
2. if i'm still alive call for intralipid immediately and airway cart
3. supplemental O2
4. place full set of monitors
5. hang intralipid ready to go and monitor
6. if decompensates, call for help, start intralipid, and intubate

note that ACLS outside of chest compressions is unhelpful if intralipid is not running.

If its lido, it would depend on the dose given, but essentially similar steps. better to have plan B available rather than having to call for help as the patient starts decompensating.

 

[DO4lifer]

76 year old for a biliary diversion in interventional radiology. 4 foot 9", 40kg, malnourished and jaundiced secondary to pancreatic CA, which is why she is having the procedure. She is nauseated and unable to eat. There is an anterior mediastinal mass seen on CT just at the level of the carina. There is no compression. There is no tracheal deviation.

BP 90/40. HR 95.
Hb 10.5 g/dL
Albumin 2.5
K 4.9 meq/dL

Airway: 1.5 FB from chin to hyoid. No teeth. good mouth opening. Uvuala seen.


Radiologists says this will most likely be difficult and long. As a side note, there is a national shortage of Etomidate, so there is none in the hospital.


1. have suction available
2. have airway cart available and if possible GlideScope
3. if possible premedicate metoclopramide for the pure sake of potentially decreasing gastric contents and premedicate with famotidine for the sake of increasing gastric pH
4. be sure pt is euvolemic, hydrate with some IVF (LR)
5. preoxygenate well, one concern here is a mediastinal mass that may compress airway once induced, another concern is potentially difficult airway (although no teeth and good mouth opening are good signs)
6. induce with heavy dose fentanyl (200mcg) and small dose of phenylephrine (50mcg) with propofol (50mg) with succ as the paralytic (understand K 4.9). could substitute with roc which can give rapid intubating conditions depending if adequate renal function understanding that roc has biliary excretion which is an issue in this case although case is going to be long.

 

[DO4lifer]

79 yo man comes in for AAA. Hx only significant for smoking and esophageal CA for which he was treated with chemo/radiation. He is a Jehovah's witness, but is willing to consider cell-saver (here's a bone for you).

 

[Idiopathic]

79 yo man comes in for AAA. Hx only significant for smoking and esophageal CA for which he was treated with chemo/radiation. He is a Jehovah's witness, but is willing to consider cell-saver (here's a bone for you).

+/- art line, one IV, standard monitors, 1 versed/50 fentanyl and endovascular AAA repair. possible epidural if surgeon requests for the groin ouchie.

 

[Idiopathic]

also remember for increta/percreta frequently they will try deliver the baby and come back to get the placent, after methotrexate therapy and allowing everything to get less vascular. Best laid plans, however...

The 3 Ive done have all needed multiple blood products, pressors, hysterectomy and SICU admission, so there is a zero percent chance that I dont put a RIJ MAC in. remember there is nothing really they can clamp to gain proximal control, and most of the bleeding is venous, even with pre-procedure uterine artery ballooning you may still have significant plexus bleeding and will also likely need hysterectomy.

just a thought

 

[DO4lifer]

+/- art line, one IV, standard monitors, 1 versed/50 fentanyl and endovascular AAA repair. possible epidural if surgeon requests for the groin ouchie.

im assuming you are planning to do this MAC? nothing wrong with that....but what if i tell you now that there is some bleeding, maybe even a dissection. looks like they are going to open. now what?

 

[somedumbDO]

it increases the sz threshold (less perfusion to the brain).

incorrect

 

[Idiopathic]

im assuming you are planning to do this MAC? nothing wrong with that....but what if i tell you now that there is some bleeding, maybe even a dissection. looks like they are going to open. now what?

consider preop line based on suspected dx (tear vs. dissection) and stability. hang norepi and nitro/nicardipine, give albumin if okay with patient (25% or 5%), setup cell saver with dedicated tubing into MAC, once in place. at this point its a level 1 trauma/damage control and a tear will necessitate an aortic cross clamp fairly quickly while you may have some more time with a dissection as long as its stable. i prefer a preop line if patient is stable enough or at least a large bore second IV prior to induction

induce with prop/sux, Glidescope ready based on airway exam. tight BP control. in anything but an elective AAA repair I require that the surgeon is in the room and the abdomen is prepped and draped prior to induction, unless the patient is actively coding.

 

[Arch Guillotti]

79 yo man comes in for AAA. Hx only significant for smoking and esophageal CA for which he was treated with chemo/radiation. He is a Jehovah's witness, but is willing to consider cell-saver (here's a bone for you).

Find out how serious he is about the whole Jehova's witness thing once he is away from his family and support system.

 

[Arch Guillotti]

The 3 Ive done have all needed multiple blood products, pressors, hysterectomy and SICU admission, so there is a zero percent chance that I dont put a RIJ MAC in.

I have done cases like this with peripherals only (14 gauges that run like hoses) as well as other similar cases (emergent ruptured AAA, etc). A central line is nice but I don't think it is necessary by any stretch of the means.

 

[Idiopathic]

I have done cases like this with peripherals only (14 gauges that run like hoses) as well as other similar cases (emergent ruptured AAA, etc). A central line is nice but I don't think it is necessary by any stretch of the means.

i get the argument that you dont have to have a central line and i wouldnt hold up an emergent case for line placement. however, these are not straightforward cases, gravid females frequently present IV access issues, and they are usually not emergent, so I take the 20 minutes and put a line in. i will not regret it.

 

[Lee123]

76 year old for a biliary diversion in interventional radiology. 4 foot 9", 40kg, malnourished and jaundiced secondary to pancreatic CA, which is why she is having the procedure. She is nauseated and unable to eat. There is an anterior mediastinal mass seen on CT just at the level of the carina. There is no compression. There is no tracheal deviation.

BP 90/40. HR 95.
Hb 10.5 g/dL
Albumin 2.5
K 4.9 meq/dL

Airway: 1.5 FB from chin to hyoid. No teeth. good mouth opening. Uvuala seen.


Radiologists says this will most likely be difficult and long. As a side note, there is a national shortage of Etomidate, so there is none in the hospital.


1. have suction available
2. have airway cart available and if possible GlideScope
3. if possible premedicate metoclopramide for the pure sake of potentially decreasing gastric contents and premedicate with famotidine for the sake of increasing gastric pH
4. be sure pt is euvolemic, hydrate with some IVF (LR)
5. preoxygenate well, one concern here is a mediastinal mass that may compress airway once induced, another concern is potentially difficult airway (although no teeth and good mouth opening are good signs)
6. induce with heavy dose fentanyl (200mcg) and small dose of phenylephrine (50mcg) with propofol (50mg) with succ as the paralytic (understand K 4.9). could substitute with roc which can give rapid intubating conditions depending if adequate renal function understanding that roc has biliary excretion which is an issue in this case although case is going to be long.

Your propofol/fentanyl on this frail patient causes the pressure to become unreadable and now that you have given the sux you are unable to ventilate the patient. Now what?.....

 

[DO4lifer]

Your propofol/fentanyl on this frail patient causes the pressure to become unreadable and now that you have given the sux you are unable to ventilate the patient. Now what?.....

1. use the glidescope
2. if no dice then use the airway cart
3. if no good then slip in LMA, use low pressures since airway not secured and concern for aspiration of gastric contents

 

[Idiopathic]

1. use the glidescope
2. if no dice then use the airway cart
3. if no good then slip in LMA, use low pressures since airway not secured and concern for aspiration of gastric contents

glidescope doesnt work (wont turn on). LMA wont seat. Sats are 60, SBP is 60, HR is 60

 

[DO4lifer]

consider preop line based on suspected dx (tear vs. dissection) and stability. hang norepi and nitro/nicardipine, give albumin if okay with patient (25% or 5%), setup cell saver with dedicated tubing into MAC, once in place. at this point its a level 1 trauma/damage control and a tear will necessitate an aortic cross clamp fairly quickly while you may have some more time with a dissection as long as its stable. i prefer a preop line if patient is stable enough or at least a large bore second IV prior to induction

induce with prop/sux, Glidescope ready based on airway exam. tight BP control. in anything but an elective AAA repair I require that the surgeon is in the room and the abdomen is prepped and draped prior to induction, unless the patient is actively coding.

learning point on this one is actually the esophageal tumor radiation. anatomy is screwed up and radiation just roasted the airway. difficult mask, difficult tube, and surgical airway difficult.

recommend having more than Glidescope in room, essentially the airway cart. even if just a MAC case, possible difficult airway, would be smooth.

obviously if there is time, give propofol then see if maskable, then give succ.

 

[DO4lifer]

glidescope doesnt work (wont turn on). LMA wont seat. Sats are 60, SBP is 60, HR is 60

i'm letting the succ wear off to prep for awake intubation. in the mean time, i'll use the fiberoptic to intubate after a squirt of epinephrine to keep vitals up and airways open just in case this is a bronchospasm.

 

[Idiopathic]

learning point on this one is actually the esophageal tumor radiation. anatomy is screwed up and radiation just roasted the airway. difficult mask, difficult tube, and surgical airway difficult.

recommend having more than Glidescope in room, essentially the airway cart. even if just a MAC case, possible difficult airway, would be smooth.

obviously if there is time, give propofol then see if maskable, then give succ.

yeah i get what you are saying. if you have time then you can do whatever you want with the airway, if you dont have time (i.e. tear in the aorta) then you probably wont be "waking up the patient" so i wouldnt waste time masking. you could also make the case for elective intubation if the airway looks challenging, but if there are no external signs (extremely limited mobility or known hx of supraglottic mass) then i think i would be comfortable with MAC abd GETA as backup

my experience with radiation-induced problems with the airway is usually in the setting of head and neck cancer rather than esophageal CA, as well, since most esophageal masses are far enough away from the cords that i dont anticipate problems with intubation. Id be much more concerned about this in the ENT patient, but airway exam and history trumps all

 

[Idiopathic]

i'm letting the succ wear off to prep for awake intubation. in the mean time, i'll use the fiberoptic to intubate after a squirt of epinephrine to keep vitals up and airways open just in case this is a bronchospasm.

so you have 5 minutes to wait?

my "learning point" is: always try everything under the sun. mention bilateral nasal trumpets, oral airway, three person mask ventilation, blind nasal intubation, etc...

do you think the anterior mediastinal mass is pertinent?

 

[pd4emergence]

Assuming there is no fetal distress and assuming the patient is a candidate for an epidural, I would place an epidural for postop pain control. Then, assuming a normal airway, I would preoxygenate the patient with 100% O2, and with cricoid pressure place a 6.0 ETT using half a mac of Sevo and half a mac of N20 for maintenace in order to decrease the risk of uterine atony that could also increase the risk of bleeding. I would then place a postinduction arterial line for blood draws and beat to beat monitoring. I would make sure to have either two large bore IVs or a cordis.

As far as a cell saver, I believe there would be no contrainduction.

In a board situation I would not mention placing a epidural in this lady. Especially if the plan is to go to sleep. Generally the most conservative, simplest plan is the easiest to defend. They may make you go down a certain path, ie saying this lady has an atrocious airway and forcing you to either do an awake foi or explain why or why not you would go the regional route. To me the potential for massive bleeding and subsequent coagulopathy is very real in this case. You would have to defend doing an epidural in that setting when you otherwise wouldn't have to.

 

[Lee123]

1. use the glidescope
2. if no dice then use the airway cart
3. if no good then slip in LMA, use low pressures since airway not secured and concern for aspiration of gastric contents

You are missing the big issue here. You easily pass the tube, but you can not ventilate at all: complete obstruction that does not resolve with epinephrine. As mentioned before, the pressure is unreadable. Remember, you are alone in radiology, your nearest help is 5 minutes away if available at all. The radiology nurses will not be that efficient paging your backup since you are busy scrambling. Do you even think they know how to do CPR in radiology?

Furthermore, you have no idea how much time is required for that sux to wear off, given her poor physical status
http://en.wikipedia.org/wiki/Cholinesterase

She is blue and pulseless. How long do you think this can go on before she is brain dead? This case is done at this point.

 

[sevoflurane]

3 y/o for T&A. No past medical history.

On examination, heart ascultation reveals splitting of S2. How do you proceed?

What if it was a holosystolic murmur?

 

[sevoflurane]

What if the same kid had one arm/hand that appeared smaller than the other... but otherwise no medical history.

 

[DO4lifer]

You are missing the big issue here. You easily pass the tube, but you can not ventilate at all: complete obstruction that does not resolve with epinephrine. As mentioned before, the pressure is unreadable. Remember, you are alone in radiology, your nearest help is 5 minutes away if available at all. The radiology nurses will not be that efficient paging your backup since you are busy scrambling. Do you even think they know how to do CPR in radiology?

Furthermore, you have no idea how much time is required for that sux to wear off, given her poor physical status
http://en.wikipedia.org/wiki/Cholinesterase

She is blue and pulseless. How long do you think this can go on before she is brain dead? This case is done at this point.

you're right i didn't understand the question. when it was said "cannot ventilate" i took that as not maskable rather than intubated and not ventilating.

since we are saying she is tubed and not ventilating, then we have to determine cause starting with the likely mediastinal mass, in which case trying to mainstem the tube beyond the obstruction would be an option. since it starting to sound like PEA, going down the causes of Hs and Ts in the setting of not ventilating, would have to rule out tension by listening for breath sounds.

 

[pd4emergence]

3 y/o for T&A. No past medical history.

On examination, heart ascultation reveals splitting of S2. How do you proceed?

What if it was a holosystolic murmur?

This in a bleeding tonsil situation (they will find a way to make you do the case).
Also, have a plan for the kid with epiglotitis, bring back neck hematoma, mediastinal mass with and without airway compression, Turp syndrome, make sure you find out about other injuries in a trauma situation.....

 

[cincincyreds]

In a board situation I would not mention placing a epidural in this lady. Especially if the plan is to go to sleep. Generally the most conservative, simplest plan is the easiest to defend. They may make you go down a certain path, ie saying this lady has an atrocious airway and forcing you to either do an awake foi or explain why or why not you would go the regional route. To me the potential for massive bleeding and subsequent coagulopathy is very real in this case. You would have to defend doing an epidural in that setting when you otherwise wouldn't have to.

The epidural solves the issue of postop pain control.

 

[Lee123]

you're right i didn't understand the question. when it was said "cannot ventilate" i took that as not maskable rather than intubated and not ventilating.

since we are saying she is tubed and not ventilating, then we have to determine cause starting with the likely mediastinal mass, in which case trying to mainstem the tube beyond the obstruction would be an option. since it starting to sound like PEA, going down the causes of Hs and Ts in the setting of not ventilating, would have to rule out tension by listening for breath sounds.

There are a few points here for anyone taking the Boards:

First, with regard to the stem I posted, you will not be able to pass the tube past the obstruction now that she is paralyzed. The patient dies. This actually happened to a colleague who gave sux to an 8 year old in the ER with a presumed diagnosis of asthma. It turned out to be a mediastinal lymphoma. He could get the tube just past the cords, but no further. He could not ventilate and the child died. The mass, found on autopsy, caused complete obstruction.

Second, don't start taking about remote causes of PEA, talking about all the Hs and Ts; just focus on the most likely cause, which is due to the drug given. You should focus on either venodilation and loss of preload from a relatively large dose of venodilator in this 40kg, frail individual; or possibly an anaphylactic reaction. Since there is still a sinus rhythm (or sinus tachycardia unless specified), this should not be a hyperkalemic response to the sux because you would expect the EKG to change, followed by an arrest. Do you really think this patient just suddenly develops a tension pneumo seconds after propofol is given? Do you really think she suddenly threw a thrombus or became acidotic when she was fine seconds ago? You need to determine the most likely cause and treat it.

A proper response for the PEA would be, "given her weight and poorly norished state and low albumin, the 50mg of propofol is the most likely cause, resulting in massive venous dilation and loss of preload. I will open the fluids and give phenylephrine if the heart rate is elevated to vasoconstrict. If this is inadequate I will move to more potent agents like norepinephrine or vasopressin."

If the examiner wants to know the extent of your knowledge base for all causes of PEA, he will ask you to list the full differential.

 

[DO4lifer]

There are a few points here for anyone taking the Boards:

First, with regard to the stem I posted, you will not be able to pass the tube past the obstruction now that she is paralyzed. The patient dies. This actually happened to a colleague who gave sux to an 8 year old in the ER with a presumed diagnosis of asthma. It turned out to be a mediastinal lymphoma. He could get the tube just past the cords, but no further. He could not ventilate and the child died. The mass, found on autopsy, caused complete obstruction.

Second, don't start taking about remote causes of PEA, talking about all the Hs and Ts; just focus on the most likely cause, which is due to the drug given. You should focus on either venodilation and loss of preload from a relatively large dose of venodilator in this 40kg, frail individual; or possibly an anaphylactic reaction. Since there is still a sinus rhythm (or sinus tachycardia unless specified), this should not be a hyperkalemic response to the sux because you would expect the EKG to change, followed by an arrest. Do you really think this patient just suddenly develops a tension pneumo seconds after propofol is given? Do you really think she suddenly threw a thrombus or became acidotic when she was fine seconds ago? You need to determine the most likely cause and treat it.

A proper response for the PEA would be, "given her weight and poorly norished state and low albumin, the 50mg of propofol is the most likely cause, resulting in massive venous dilation and loss of preload. I will open the fluids and give phenylephrine if the heart rate is elevated to vasoconstrict. If this is inadequate I will move to more potent agents like norepinephrine or vasopressin."

If the examiner wants to know the extent of your knowledge base for all causes of PEA, he will ask you to list the full differential.

so whats the proper answer for the unable to ventilate?