Postop complicaition in PACU scenario

[excalibur]

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? I don't understand ....I think I'm confused to what you are referring to or where we are in the case...


But as I rethink the scenario with the expanding hematoma,

Original cea was awake + airway isn't yet compromised + surgeon is there = make sure our block is still working, go to OR and not have to induce

You said first OR case u saw in OR from anesthesia side was an awake CEA. So I asked why were you trying to intubate a patient who was scheduled for awake CEA.

 

[bkell101]

Cea originally done awake + airway compromised + surgeon is there ....

Same answer...incision to relieve the fixed compartment and no need to go to sleep

 

[bkell101]

You said first OR case u saw in OR from anesthesia side was an awake CEA. So I asked why were you trying to intubate a patient who was scheduled for awake CEA.

Ohhhhhhhh hahahaha you are totally right, just goes to show how confused I was and still am.

I think I mashed two memories into one ....both cases were on my first day though, I think

 

[bkell101]

Wondering if the same thing won't happen my first day in the or as a ca1, hahahah ( I've only gotten to do one week anesthesia this year so far, so it'll kinda be my first day all over again)

 

[anes]

Your status says that you r premed. Are you an EMT?

Why were they offering to let you intubate?

 

[Agast]

So can the above not be accomplished with the patient awake?

I'm talking about taking the patient back to the OR for surgery vs. decompressing at bedside. But in the OR I wouldn't attempt to do this case awake, depending on how the neck looks the planes might be distorted by underlying hematoma and nerve block might fail. Without secured airway I'm not going to supplement crappy block with sedation.

 

[excalibur]

Knock, Knock, Knock

ORAL BOARD EXAMINER's reply:

Thank you. That is all the time we have.

Very interesting discussion.

Here is how it went down for me.

Pt was bleeding in PACU as described and hypertensive as described. Yes, I gave hydralazine. Sorry, Venty. BP stabilized for a bit. Bleeding picked up. Pt went brady with HR 34 and BP of 45/15 on art line. Pt awake. I gave 0.2 mg of Atropine as I didn't want to overshoot it. Again pt was awake during this time, which was amazing to me as I felt like doing compressions.

When bleeding was at 650 mL and JP clotted, the surgeons arrived. The neck was swollen at this point...

Now I asked in the exercise what people would have done in the exercise if pt had gotten dyspneic. Many said secure airway if surgeon is not available meaning I guess attempt intubation. Venty menntioned awake, but I guess others were thinking IV induction, maybe RSI. I have heard and read of cases where intubation can be quite difficult with IV induction from an expanding post CEA neck hematoma. So much so that I always thought priority needs to be with decompressing the expanding hematoma first hopefully from the surgeon. But I seem to remember the "what if" scenarios from my attendings that if you are the only doctor available and many suggested decompression first even if it means you do it. Thoughts on this??

--I was not as worried about me having to do this cuz I knew I could get the surgeon to the bedside immediately as I knew where he was. But in the moment I kept thinking that this patient needs decompression first. My brain was thinking "what if" it was just me here in the actual moment.

--For those who would have done an IV induction on an unstable bleeding patient with an expanding neck hematoma, just be prepared for a possible Grade IV view (and subsequent backup plan), deviated glottis from the hemaotma, or possible cardiovascular collapse--Severe AS, hemorrhage, and IV induction.

When surgeon arrived, he agreed re-exploration was necessary. So how did we induce anesthesia? With local infiltration. Prep, Drape, Local infiltration by surgeon, and cut. We gave 2 units of pRBC's and 1 unit of platelets. Held O2 facemask by his face. Guy did fine. It turned out that a surgical clip had come loose resulting in a bleeding vessel. One of our partners stated he was glad we just did it under local as he recalled a similar situation in his past where they went for re-exploration, he opted for general anesthesia, and he could not intubate the patient.

Also although I didn't mention it, our two CT surgeons do all their CEA's awake. The surgeons do their own local anesthesia administration. They do a superficial block for superficial dissection, they dissect, and then they inject more around carotid artery when they arrive there. Our suegeons are very accustomed to CEA's under local, so that is how we did the re-exploration.

 

[bkell101]

Your status says that you r premed. Are you an EMT?

Why were they offering to let you intubate?

On no, sorry I'm an intern (prelim medicine doing anesthesia)....I just haven't updated my profile

 

[VentdependenT]

Great scenerio with a better happy ending than that provided by massage parlors. Great teaching points.

 

[bkell101]

Knock, Knock, Knock

ORAL BOARD EXAMINER's reply:

Thank you. That is all the time we have.

Very interesting discussion.

Here is how it went down for me.

Pt was bleeding in PACU as described and hypertensive as described. Yes, I gave hydralazine. Sorry, Venty. BP stabilized for a bit. Bleeding picked up. Pt went brady with HR 34 and BP of 45/15 on art line. Pt awake. I gave 0.2 mg of Atropine as I didn't want to overshoot it. Again pt was awake during this time, which was amazing to me as I felt like doing compressions.

When bleeding was at 650 mL and JP clotted, the surgeons arrived. The neck was swollen at this point...

Now I asked in the exercise what people would have done in the exercise if pt had gotten dyspneic. Many said secure airway if surgeon is not available meaning I guess attempt intubation. Venty menntioned awake, but I guess others were thinking IV induction, maybe RSI. I have heard and read of cases where intubation can be quite difficult with IV induction from an expanding post CEA neck hematoma. So much so that I always thought priority needs to be with decompressing the expanding hematoma first hopefully from the surgeon. But I seem to remember the "what if" scenarios from my attendings that if you are the only doctor available and many suggested decompression first even if it means you do it. Thoughts on this??

--I was not as worried about me having to do this cuz I knew I could get the surgeon to the bedside immediately as I knew where he was. But in the moment I kept thinking that this patient needs decompression first. My brain was thinking "what if" it was just me here in the actual moment.

--For those who would have done an IV induction on an unstable bleeding patient with an expanding neck hematoma, just be prepared for a possible Grade IV view (and subsequent backup plan), deviated glottis from the hemaotma, or possible cardiovascular collapse--Severe AS, hemorrhage, and IV induction.

When surgeon arrived, he agreed re-exploration was necessary. So how did we induce anesthesia? With local infiltration. Prep, Drape, Local infiltration by surgeon, and cut. We gave 2 units of pRBC's and 1 unit of platelets. Held O2 facemask by his face. Guy did fine. It turned out that a surgical clip had come loose resulting in a bleeding vessel. One of our partners stated he was glad we just did it under local as he recalled a similar situation in his past where the for re-exploration, he opted for general anesthesia, and he could not intubate the patient.

Also although I didn't mention it, our two CV anesthesia guys do all their CEA's awake. The surgeons do their own local anesthesia administration. They do a superficial block for superficial dissection, they dissect, and then they inject more around carotid artery when they arrive there. Our suegeons are very accustomed to CEA's under local, so that is how we did the re-exploration.

Really cool post/case....always so humbling to see how far off I am....then again that's the beauty of this site.

 

[bkell101]

What would macgyver do if no surgeon was available?

 

[bkell101]

Great scenerio with a better happy ending than that provided by massage parlors. Great teaching points.

Hahaha you're goin to the wrong massage Parlers man

 

[Arch Guillotti]

Good case.

If the patient is decompensating I might treat it like a ruptured AAA or crash c/s. Get the patient to the OR, prep, drape then induce with surgeon ready to go.

I know of a case very similar to this except the patient crashed and burned in the OR. Airway was lost and truly was a can't intubate/ventilate scenario. Patient ended up with a trach and thankfully did fine.

 

[Mman]

Knock, Knock, Knock

ORAL BOARD EXAMINER's reply:

Thank you. That is all the time we have.

Very interesting discussion.

Here is how it went down for me.

Pt was bleeding in PACU as described and hypertensive as described. Yes, I gave hydralazine. Sorry, Venty. BP stabilized for a bit. Bleeding picked up. Pt went brady with HR 34 and BP of 45/15 on art line. Pt awake. I gave 0.2 mg of Atropine as I didn't want to overshoot it. Again pt was awake during this time, which was amazing to me as I felt like doing compressions.

When bleeding was at 650 mL and JP clotted, the surgeons arrived. The neck was swollen at this point...

Now I asked in the exercise what people would have done in the exercise if pt had gotten dyspneic. Many said secure airway if surgeon is not available meaning I guess attempt intubation. Venty menntioned awake, but I guess others were thinking IV induction, maybe RSI. I have heard and read of cases where intubation can be quite difficult with IV induction from an expanding post CEA neck hematoma. So much so that I always thought priority needs to be with decompressing the expanding hematoma first hopefully from the surgeon. But I seem to remember the "what if" scenarios from my attendings that if you are the only doctor available and many suggested decompression first even if it means you do it. Thoughts on this??

--I was not as worried about me having to do this cuz I knew I could get the surgeon to the bedside immediately as I knew where he was. But in the moment I kept thinking that this patient needs decompression first. My brain was thinking "what if" it was just me here in the actual moment.

--For those who would have done an IV induction on an unstable bleeding patient with an expanding neck hematoma, just be prepared for a possible Grade IV view (and subsequent backup plan), deviated glottis from the hemaotma, or possible cardiovascular collapse--Severe AS, hemorrhage, and IV induction.

When surgeon arrived, he agreed re-exploration was necessary. So how did we induce anesthesia? With local infiltration. Prep, Drape, Local infiltration by surgeon, and cut. We gave 2 units of pRBC's and 1 unit of platelets. Held O2 facemask by his face. Guy did fine. It turned out that a surgical clip had come loose resulting in a bleeding vessel. One of our partners stated he was glad we just did it under local as he recalled a similar situation in his past where they went for re-exploration, he opted for general anesthesia, and he could not intubate the patient.

Also although I didn't mention it, our two CT surgeons do all their CEA's awake. The surgeons do their own local anesthesia administration. They do a superficial block for superficial dissection, they dissect, and then they inject more around carotid artery when they arrive there. Our suegeons are very accustomed to CEA's under local, so that is how we did the re-exploration.

Reasonable approach. My partner had one of these in PACU a few months ago. Surgeon popped some sutures out in PACU so they could intubate and then they transferred to OR for exploration to fix the problem definitively. If the patient was easy to intubate preop, they will likely be easy if the hematoma is decompressed. If it isn't decompressed, it's anybody's guess what's going on down there.

In real life, I'd be happy to proceed with an RSI with a glidesope provided I had a surgeon with a scalpel standing by to release the hematoma for me if I couldn't see anything. Nothing wrong with putting in some local, though, and having a going at it knowing you might need to intubate at a moment's notice under the drapes.

 

[Mman]

What would macgyver do if no surgeon was available?

cut the stitches holding the skin and fascia closed and release the pressure of the hematoma. Doesn't sound like fun, but it's not technically difficult and is life saving in this situation.


Let's put it this way, I'd be more comfortable doing that with a knife than doing an emergency cric, but your gotta do what you gotta do.

 

[excalibur]

Reasonable approach.

In real life, I'd be happy to proceed with an RSI with a glidesope provided I had a surgeon with a scalpel standing by to release the hematoma for me if I couldn't see anything. Nothing wrong with putting in some local, though, and having a going at it knowing you might need to intubate at a moment's notice under the drapes.

This is another lesson to the residents. Different strokes for different folks. Many ways to skin a cat. Your approaches have to be reasonable, though, and you have to explain why you chose that approach.

Regarding RSI c Glidescope after pt is prepped and draped and surgeon is sitting there with scalpel...Here is my thought: Pt is breathing, but is having difficulty because of an expanding neck hematoma compressing his larynx/trachea. Once that is decompressed by cutting the sutures his breathing should improve dramatically. Why then would you prep, drape, have surgeon ready with scalpel, and then... render pt apneic (IV induction) hoping you could intubate to then have surgeon cut, when you could have everything prepped, give surgeon 20 mL of Lido 1%, and have him cut while pt maintains spontaneous respirations. In both scenarios your intubating under the drapes, and in both scenarios intubation is likely difficult because of the hematoma.

So my point is if you are going to get everything ready, including the surgeon with scalpel, and the intubation is likely going to be difficult if it's attempted, why would you opt for RSI? Instead of you pushing etomidate, have the surgeon inject lidocaine along the suture line. This should be sufficient, pt should improve fairly quickly after incision, and guess what if local not sufficient and pt/surgeon not happy, then you can induce. I can't imagine the intubation was gonna be harder now then a few minutes ago.

In essence it should be the other way around. Prep, drape, surgeon ready with scalpel, then surgeon injects 20 mL of local for infiltration, and as he prepares for incision, anesthesiologist is ready with RSI and Glidescope if pt becomes combative or insufficient anesthesia.

Our CT surgeon simply told pt in PACU, "Sir, you're having a little more bleeding than we like, so we gotta take a quick peek in there. We will take you back there, I will numb you up again, and we'll have a look". It really should be as simple as that, and it was.

Picture it. Everyone in OR and we are ready to cut, pt dyspneic (still breathing) and cutting sutures decompressing hematoma should assuredly improve breathing.

We can
A) use local infiltration , incise with pt awake and dyspneic (still breathing) but once incision takes place, breathing should improve. RSI c Glidescope is backup if pt becomes combative from pain knowing intubation could be difficult.

B) Knowing intubation could be difficult we opt to render the dyspneic (still breathing) pt apneic (not breathing), HOPE we can intubate, and if can't intubate, THEN we ask surgeon to decompress. In A) Decompression in a breathing pt should help pt's breathing. Here in B) we are hoping decompression helps us intubate or ventilate a pt we rendered apneic.

If you are gonna get everything and everyone ready, why choose B when A and 20 mL of local will do?

 

[bkell101]

Seems decompression first and re-evaluation of the airway second is the way to go if if the surgeon is there. This was a great learning lesson.

 

[bkell101]

cut the stitches holding the skin and fascia closed and release the pressure of the hematoma. Doesn't sound like fun, but it's not technically difficult and is life saving in this situation.


Let's put it this way, I'd be more comfortable doing that with a knife than doing an emergency cric, but your gotta do what you gotta do.

If you are the only one in the middle of the night covering sicu and patient is desatting, then I guess you just gotta go trach vs decompression which ever you are more comfortable with.

Now knowing how difficult the airway could potentially be, I really don't like the idea of inducing before addressing the primary problem

 

[bkell101]

Much learned from this thread, thanks, looking forward to more.

 

[caligas]

This is another lesson to the residents. Different strokes for different folks. Many ways to skin a cat. Your approaches have to be reasonable, though, and you have to explain why you chose that approach.

Regarding RSI c Glidescope after pt is prepped and draped and surgeon is sitting there with scalpel...Here is my thought: Pt is breathing, but is having difficulty because of an expanding neck hematoma compressing his larynx/trachea. Once that is decompressed by cutting the sutures his breathing should improve dramatically. Why then would you prep, drape, have surgeon ready with scalpel, and then... render pt apneic (IV induction) hoping you could intubate to then have surgeon cut, when you could have everything prepped, give surgeon 20 mL of Lido 1%, and have him cut while pt maintains spontaneous respirations. In both scenarios your intubating under the drapes, and in both scenarios intubation is likely difficult because of the hematoma.

So my point is if you are going to get everything ready, including the surgeon with scalpel, and the intubation is likely going to be difficult if it's attempted, why would you opt for RSI? Instead of you pushing etomidate, have the surgeon inject lidocaine along the suture line. This should be sufficient, pt should improve fairly quickly after incision, and guess what if local not sufficient and pt/surgeon not happy, then you can induce. I can't imagine the intubation was gonna be harder now then a few minutes ago.

In essence it should be the other way around. Prep, drape, surgeon ready with scalpel, then surgeon injects 20 mL of local for infiltration, and as he prepares for incision, anesthesiologist is ready with RSI and Glidescope if pt becomes combative or insufficient anesthesia.

Our CT surgeon simply told pt in PACU, "Sir, you're having a little more bleeding than we like, so we gotta take a quick peek in there. We will take you back there, I will numb you up again, and we'll have a look". It really should be as simple as that, and it was.

Picture it. Everyone in OR and we are ready to cut, pt dyspneic (still breathing) and cutting sutures decompressing hematoma should assuredly improve breathing.

We can
A) use local infiltration , incise with pt awake and dyspneic (still breathing) but once incision takes place, breathing should improve. RSI c Glidescope is backup if pt becomes combative from pain knowing intubation could be difficult.

B) Knowing intubation could be difficult we opt to render the dyspneic (still breathing) pt apneic (not breathing), HOPE we can intubate, and if can't intubate, THEN we ask surgeon to decompress. In A) Decompression in a breathing pt should help pt's breathing. Here in B) we are hoping decompression helps us intubate or ventilate a pt we rendered apneic.

If you are gonna get everything and everyone ready, why choose B when A and 20 mL of local will do?

Expanding hematoma in spontaneously breathing patient gets awake intubation or surgical decompression. Those are the only acceptable options.

 

[Laryngophed]

Much learned from this thread, thanks, looking forward to more.

Agreed. Thanks for posting the case excalibur and all who contributed.

 

[Ignatius J]

Ex,

Just curiously and maybe a dumb question, but what's the reasoning behind both the bradycardia and simultaneous hypotension? I could see bradycardia with hypertension and tachycardia with hypotension given the bleeding, but I don't understand the pathophysiology behind this clinical scenario.

 

[partydoc]

Ex,

Just curiously and maybe a dumb question, but what's the reasoning behind both the bradycardia and simultaneous hypotension? I could see bradycardia with hypertension and tachycardia with hypotension given the bleeding, but I don't understand the pathophysiology behind this clinical scenario.

I was thinking he was probably b blocked.

 

[Arch Guillotti]

Expanding hematoma in spontaneously breathing patient gets awake intubation or surgical decompression. Those are the only acceptable options.

I think an awake intubation is for sure the safest thing. Unfortunately sometimes the patient can crump while you are getting everything set up. Cases like this have the potential to decompensate right in front of your eyes. Patient may be hypoxic/combative/uncooperative. Cases like this can really force your hand. All the difficult airway devices/adjuncts may not be readily available or you may not have tech support or it may be the middle of the night or somesuch idiocy. I think the most important thing is having a surgeon who can open the damn thing up and is familiar with surgical airways.

 

[excalibur]

Ex,

Just curiously and maybe a dumb question, but what's the reasoning behind both the bradycardia and simultaneous hypotension? I could see bradycardia with hypertension and tachycardia with hypotension given the bleeding, but I don't understand the pathophysiology behind this clinical scenario.

Possible vagal from stimulation of carotid from holding pressure?

Or he was knock, knock, knocking on heaven's door from acute hemorrhage and beta blockade combo

 

[excalibur]

I think an awake intubation is for sure the safest thing. Unfortunately sometimes the patient can crump while you are getting everything set up. Cases like this have the potential to decompensate right in front of your eyes. Patient may be hypoxic/combative/uncooperative. Cases like this can really force your hand. All the difficult airway devices/adjuncts may not be readily available or you may not have tech support or it may be the middle of the night or somesuch idiocy. I think the most important thing is having a surgeon who can open the damn thing up and is familiar with surgical airways.

Agree. Worry more about getting surgeon there quickly instead of getting tube in quickly.

 

[Mman]

If you are the only one in the middle of the night covering sicu and patient is desatting, then I guess you just gotta go trach vs decompression which ever you are more comfortable with.

Now knowing how difficult the airway could potentially be, I really don't like the idea of inducing before addressing the primary problem

Nobody, surgeon included is doing a trach or cric in this patient. Too much blood in the neck and too much distorted anatomy. The only thing a sharp instrument will do is open up the wound to decompress the hematoma.


As to anybody's previous assertion that the patient would need an awake intubation if you are putting a tube in, what do you do if they become combative? They weren't breathing that well before you stuck a scope in their posterior pharynx. Your topicalization is likely less than ideal. Their CO2 is now rising. Their neck keeps expanding... And on and on and on. In my limited experience with this type of situation, an awake FOI sounds easier than it is. Because they aren't breathing well and their anatomy is already screwed up. I'd be willing to entertain the idea, but I'd much rather just have somebody stick a knife in their neck to relieve the swelling, even if that somebody is me.

 

[Oggg]

You can take care of 1L blood loss in your sleep. Hematoma crushing trachea, not so much.

 

[Mapleson D]

My more senior colleagues warn that releasing the sutures in a scenario like this may not cause the miraculous improvement in airway conditions that you hope. That the associated tissue edema is not so easily reversible.

Thoughts on this, Excalibur?

Great case.

 

[excalibur]

My more senior colleagues warn that releasing the sutures in a scenario like this may not cause the miraculous improvement in airway conditions that you hope. That the associated tissue edema is not so easily reversible.

Thoughts on this, Excalibur?

Great case.

What is not easily reversible is APNEA in someone you can't ventilate or intubate.

In expanding neck hematoma, mask ventilation and intubation can be very difficult, so I feel that rendering a pt apneic through induction is risky.

Loosening the sutures may improve SPONTANEOUS breathing. If it does not, THEN you can proceed with induction and intubation. I can't imagine you make spontaneous ventilation or intubation conditions much worse by loosening the sutures, but with induction first you eliminate spontaneous ventilation, and it has been shown through case reports that intubation can be difficult.

The situation is not a fun one, and there are no easy answers, and filled with "what if's?" BUT...

If you induce a pt with expanding neck hematoma, what happens next if you can't intubate or effectively mask ventilate? Do you release the sutures, then?? If that's the case, why wouldn't you try that first???

If you loosen the sutures first, and breathing does not improve, then you can roll the dice and try induction and intubation with cric kit nearby. Again I just don't feel you make intubation conditions worse by loosening sutures.

Hopefully in these scenarios, the surgeon is nearby and you are not solo, but if surgeon is available, I still feel loosening the sutures first is the way to go.

As in my case the whole procedure was done under local, and his breathing improved, and the "tissue edema" was resolved. Again the surgeon was there suctioning blood and addressing the bleeding vessel. In scenarios where the surgeon is right there, and ready to cut, I don't see why you would want to attempt induction first instead of loosening the sutures first.

I understand more so the hesitancy of an anesthesiologist wanting to re-open the wound as he/she is inexperienced in that regard

 

[Mman]

My more senior colleagues warn that releasing the sutures in a scenario like this may not cause the miraculous improvement in airway conditions that you hope. That the associated tissue edema is not so easily reversible.

Thoughts on this, Excalibur?

Great case.

It generally isn't edema causing the airway obstruction, it's physical compression from the expanding hematoma and if you release the pressure that resolves very quickly. Assuming you don't stab a scalpel down into the carotid, there is essentially no major risk from cutting the sutures. I mean the patient is already needing to go back to the OR.