out of OR case

[Idiopathic]

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55 year old male, presents to radiology holding. history of anterior mediastinal lymphoma, with 7X3cm mass stable over last three months. mass compresses SVC almost completely, but no sign of tracheal or esophageal compression. Good collaterals by CT and patent IVC. patient sleeps in a recliner, fed by PEG tube, although claims "can eat, just sore from a fungal infection". Reports that he cant lean forward (i.e. put his head below his heart) without blacking out almost immediately, although he can lay completely flat for things like CT scan and radiation therapy. History of NIDDM and HTN as well, fairly well controlled. CPAP at night, no increased O2 requirement.

PE: Has XRT markings on chest, large neck, obvious venous congestion. Class I/II airway with good oral opening, beard. Ears, lips, eyes, nose all have the appearance of normal skin, not purple or blue, although he reports some days his ears are purple by the end of the day. Normal neuro exam, normal heart sounds, almost absent right chest sounds, when questioned about this reports "oh yeah the tumor is supposedly interfering with the nerve that controls that side of the diaphragm so it doesnt work". Venous collaterals visible on chest.

IR wants to access the IJ and the groin to pass an SVC stent from the leg and follow that up with placement of a tunnelled IJ port.

Whats your next move

 

[Planktonmd]

55 year old male, presents to radiology holding. history of anterior mediastinal lymphoma, with 7X3cm mass stable over last three months. mass compresses SVC almost completely, but no sign of tracheal or esophageal compression. Good collaterals by CT and patent IVC. patient sleeps in a recliner, fed by PEG tube, although claims "can eat, just sore from a fungal infection". Reports that he cant lean forward (i.e. put his head below his heart) without blacking out almost immediately, although he can lay completely flat for things like CT scan and radiation therapy. History of NIDDM and HTN as well, fairly well controlled. CPAP at night, no increased O2 requirement.

PE: Has XRT markings on chest, large neck, obvious venous congestion. Class I/II airway with good oral opening, beard. Ears, lips, eyes, nose all have the appearance of normal skin, not purple or blue, although he reports some days his ears are purple by the end of the day. Normal neuro exam, normal heart sounds, almost absent right chest sounds, when questioned about this reports "oh yeah the tumor is supposedly interfering with the nerve that controls that side of the diaphragm so it doesnt work". Venous collaterals visible on chest.

IR wants to access the IJ and the groin to pass an SVC stent from the leg and follow that up with placement of a tunnelled IJ port.

Whats your next move

Easy!
1 mg Midazolam and tell them to do good local anesthesia.

 

[Idiopathic]

are you concerned about anything? do you want anything answered pre-procedure? is there anything that could go wrong? can you do this procedure in the reclined position?

 

[Planktonmd]

are you concerned about anything? do you want anything answered pre-procedure? is there anything that could go wrong? can you do this procedure in the reclined position?

The patient said he can lie down flat for CT scans and things like that so why do you want to do it the reclined position?
As long as you don't give him GA he is going to maintain his airway since he does not have stridor or dyspnea right now.
If the SVC is compressed by the tumor then accessing the IJ should be very easy since it is going to be distended and you should not have to put him in trendelenburg.

 

[Idiopathic]

well he can tolerate 10 minutes flat. this procedure will take 2 hours.

 

[Planktonmd]

well he can tolerate 10 minutes flat. this procedure will take 2 hours.

If he can be flat for 10 minutes then he can be flat for 2 hours.
Why do they need 2 hours though?

 

[Idiopathic]

well if he could tolerate long periods of laying flat, then he wouldnt sleep in a recliner is my impression. he can stand to lay flat for a short period of time but he clearly is in some distress even at a slight angle.

30 minutes prep time, 30 minutes to snare the groin wire, 30 minutes to place/balloon the stent, 30 minutes for the port - call it anywhere from 90 - 120 minutes from on the table to out of the room.

 

[Coastie]

55 year old male, presents to radiology holding. history of anterior mediastinal lymphoma, with 7X3cm mass stable over last three months. mass compresses SVC almost completely, but no sign of tracheal or esophageal compression. Good collaterals by CT and patent IVC. patient sleeps in a recliner, fed by PEG tube, although claims "can eat, just sore from a fungal infection". Reports that he cant lean forward (i.e. put his head below his heart) without blacking out almost immediately, although he can lay completely flat for things like CT scan and radiation therapy. History of NIDDM and HTN as well, fairly well controlled. CPAP at night, no increased O2 requirement.

PE: Has XRT markings on chest, large neck, obvious venous congestion. Class I/II airway with good oral opening, beard. Ears, lips, eyes, nose all have the appearance of normal skin, not purple or blue, although he reports some days his ears are purple by the end of the day. Normal neuro exam, normal heart sounds, almost absent right chest sounds, when questioned about this reports "oh yeah the tumor is supposedly interfering with the nerve that controls that side of the diaphragm so it doesnt work". Venous collaterals visible on chest.

IR wants to access the IJ and the groin to pass an SVC stent from the leg and follow that up with placement of a tunnelled IJ port.

Whats your next move

Why can't this be done under local only?

What's the end game surgical plan?

 

[Idiopathic]

not necessarily asking how to do the case. just trying to stimulate discussion. this is not an entirely benign procedure in and of itself

 

[dhb]

Whats your next move

I go drink a coffee.

This case should be done under local, they can recline him: air embolism isn't a concern since venous pressure is high.

 

[Idiopathic]

my thought was if you had to go to sleep urgently for whatever reason, then you would very possibly be screwed (no thoracic surgery present, anterior mediastinal mass) and there was a real chance that the SVC could get injured with the procedure, necessitating both an urgent intubation and urgent access issue (IV in the arm only).

i felt for a brief moment that I needed to intubate this guy awake to justify myself if anything went wrong (i.e. "what would a board examiner say?
")

i really spent way too much time fixating on the ins and outs of this case but it was pretty unsettling while i was preparing for it

 

[lobelsteve]

MSContin 30mg bid, Consult hospice. They can titrate to effect at home.
That should make him comfortable. Even given the small amount of data above- I would not let them keep plugging away on me.

 

[IN2B8R]

MSContin 30mg bid, Consult hospice. They can titrate to effect at home.
That should make him comfortable. Even given the small amount of data above- I would not let them keep plugging away on me.

👍

 

[hoyden]

my thought was if you had to go to sleep urgently for whatever reason, then you would very possibly be screwed (no thoracic surgery present, anterior mediastinal mass) and there was a real chance that the SVC could get injured with the procedure, necessitating both an urgent intubation and urgent access issue (IV in the arm only).

i felt for a brief moment that I needed to intubate this guy awake to justify myself if anything went wrong (i.e. "what would a board examiner say?
")

i really spent way too much time fixating on the ins and outs of this case but it was pretty unsettling while i was preparing for it

If you have to do it under GA you do not necessarily have to intubate him awake, but you can not abolish his spontaneous ventilation. With airway class 1-2 should not be a problem, however, he might have to shave his beard to facilitate the laryngoscopy conditions.
If he is crazy about his beard - he can tolerate the procedure under local

 

[Jeff05]

there is no evidence of airway compression from HandP or imaging. the only reason to keep spontaneous ventilation is to prevent decreasing already compromised venous return by PPV.

i think a reasonable approach would be to breathe him down with sevo and place an LMA. PSV can be used to support him a bit, if his hemi-diaphragm isn't getting the job done.

or run dex or remi or ketafol for a nice mac - he won't move or care what they do to him.

if they get into trouble with bleeding - you already have an introducer in the groin. popping another introducer into contralateral side is an option. the truth is, however, if they get into real bleeding, it doesn't matter what you have - short of an introducer connected to a preloaded rapid infuser with a perfusionist helping you dump RBC/FFP into it. If they perf his VC, he'll lose his blood volume in 60sec.