Pre-op visit

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Noyac

Noyac

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Middle aged female comes to pre-op clinic for interview prior to lumbar microdiscectomy. Mostly healthy, no meds, active. Long list of allergies of note though are Sevo and propofol.

History:
Pt has had many surgeries in the past but most recently had a knee scope under GA with Des and propofol for induction. 4 days later she was admitted to Hosp for acute hepatitis with elevated LFT's. ALT 2000, AST 800, ALK PHOS 500, INR 1.3. Pt c/o pruritis, nausea and loss of appetite. No other constitutional symptoms. Pt saw her primary who labeled her allergic to Sevo and propofol.
One year ago pt underwent colonoscopy with brevital without problems.

Today: she wants to have a microdiscectomy and refuses a spinal.

Plan?
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Not allergic to Sevo and/or propofol until proven otherwise. Most post-op LFT elevations have nothing to do with currently-used anesthesia drugs. I would not care for what the primary doc said, but I would do my best to get the hospital records and GI conclusions.

Plan for TIVA with propofol+fentanyl infusions. If she has doubts, she can come in for a propofol test-infusion a few weeks before the surgery, and she can get her LFT's checked before and after. My experience is limited to 5 years, but I still have to see one true allergy to propofol; same for inhalational agents, if we exclude MH.
 
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Noyac said:
Middle aged female comes to pre-op clinic for interview prior to lumbar microdiscectomy. Mostly healthy, no meds, active. Long list of allergies of note though are Sevo and propofol.

History:
Pt has had many surgeries in the past but most recently had a knee scope under GA with Des and propofol for induction. 4 days later she was admitted to Hosp for acute hepatitis with elevated LFT's. ALT 2000, AST 800, ALK PHOS 500, INR 1.3. Pt c/o pruritis, nausea and loss of appetite. No other constitutional symptoms. Pt saw her primary who labeled her allergic to Sevo and propofol.
One year ago pt underwent colonoscopy with brevital without problems.

Today: she wants to have a microdiscectomy and refuses a spinal.

Plan?
Click to expand...


PPF and Des for previous anesthetic and listed as allergic to Sevo? Unless that's a typo then obviously the PCP doesn't know what he's talking about.
 
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anes said:
PPF and Des for previous anesthetic and listed as allergic to Sevo? Unless that's a typo then obviously the PCP doesn't know what he's talking about.
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Good catch. That's what was said to the pt as well.
 
GA with isoflurane. If she doesn't care if she gets sick after I'll even give her nitrous + iso so she can wake up a smidge faster. I really don't care how to do the induction, not going to argue if someone wants to skip the propofol and use something like etomidate instead.
 
When about anesthesia drugs, most docs have no idea what they are talking about. Plus some are downright stupid: I had a patient with very bad PONV listed as allergic to scopolamine, just because she had hallucinations after leaving a patch on for 7 days. I had to convince her that she was not allergic, we put on a patch (that she removed 6 hours after the surgery), and she did great.

P.S. If no EP monitoring, nitrous + sevo should be fine, and she could be induced with brevital (would avoid etomidate for pro-emetic reasons).
 
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Mman said:
GA with isoflurane. If she doesn't care if she gets sick after I'll even give her nitrous + iso so she can wake up a smidge faster. I really don't care how to do the induction, not going to argue if someone wants to skip the propofol and use something like etomidate instead.
Click to expand...

Why not sevoflurane? Just as a CYA, because it's listed on her chart?
 
Noyac said:
Middle aged female comes to pre-op clinic for interview prior to lumbar microdiscectomy. Mostly healthy, no meds, active. Long list of allergies of note though are Sevo and propofol.

History:
Pt has had many surgeries in the past but most recently had a knee scope under GA with Des and propofol for induction. 4 days later she was admitted to Hosp for acute hepatitis with elevated LFT's. ALT 2000, AST 800, ALK PHOS 500, INR 1.3. Pt c/o pruritis, nausea and loss of appetite. No other constitutional symptoms. Pt saw her primary who labeled her allergic to Sevo and propofol.
One year ago pt underwent colonoscopy with brevital without problems.

Today: she wants to have a microdiscectomy and refuses a spinal.

Plan?
Click to expand...
The primary should submit it as a case report.

Kidding aside, why would her enzymes short up so high after a knee scope?
 
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Noyac said:
Whats the most likely cause of her acute hepatitis?
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Cholestasis versus viral. Probably a common bile duct stone (although I don't like the ALT). That's why I want to see the GI notes.

There are extremely few case reports of acute hepatitis after propofol.

This is a patient with a long list of allergies. She might be one of the very few people who are allergic to almost everything under the Sun (they exist), or she might be just ****oo (much higher prevalence). Either way, this should be a three party-discussion that should include the surgeon, his EP monitoring plan, and possibly allergy-testing for the patient preop.
 
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FFP said:
What if the surgeon wants EP monitoring?
Click to expand...

By EP you mean evoked potentials? We use sevo up to 1 mac for spines with MEP/SSEP with no issues. I'd be okay with sevo, fentanyl, and maybe dexmedetomidine :shifty:
 
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the only "likely" anesthetic cause of hepatitis would be halothane which has estimated incidence of fatal hepatitis of about 1:10,000 anesthetics and less than fatal probably far more often. Sevo or Des are almost impossible to get hepatitis from. Propofol? While metabolized hepatically it doesn't require much liver function at all to be cleared as every cirrhotics can metabolize it. There are a few case reports of acute hepatitis after propofol anesthesia but that is still extremely rare.
 
FFP said:
This is a patient with a long list of allergies. She might be one of the very few people who are allergic to almost everything under the Sun (they exist), or she might be just ****oo (much higher prevalence).
Click to expand...

Yesterday I had a patient getting a laparoscopic diverting colostomy for a bowel obstruction. Allergic to fentanyl, morphine, codeine, hydromorphone, and 5 or 6 other drugs, tape too. She was getting Toradol for pain on the ward. I asked her what happened when she got fentanyl and she said "I died" ... tried to tease out exactly what happened and all I ever got out of her was "I died." No further details forthcoming. Frustrating. She wasn't demented. I did the case with ketamine, ketorolac, acetaminophen, magnesium, and no opiates.



Desflurane certainly doesn't have the liver risk of halothane, but there are case reports of acute liver injury. Des is so minimally metabolized I usually think of it as un-metabolized, but it still has some toxic metabolites that can provoke the same antibody response that's behind halothane hepatitis. Here we've got a patient who had an episode of hepatitis immediately after anesthesia with desflurane. TIVAs are easy. I've done lots of TIVAs for weaker stories than this (funny family hx that smelled like it might possibly could've been MH).

Propofol? I just looked up a few case reports of hepatitis attributed to propofol. Two had symptoms present weeks later, not days. One was after an ERCP, ie a patient who had another reason to have an angry liver.
 
pgg said:
Yesterday I had a patient getting a laparoscopic diverting colostomy for a bowel obstruction. Allergic to fentanyl, morphine, codeine, hydromorphone, and 5 or 6 other drugs, tape too. She was getting Toradol for pain on the ward. I asked her what happened when she got fentanyl and she said "I died" ... tried to tease out exactly what happened and all I ever got out of her was "I died." No further details forthcoming. Frustrating. She wasn't demented. I did the case with ketamine, ketorolac, acetaminophen, magnesium, and no opiates.



Desflurane certainly doesn't have the liver risk of halothane, but there are case reports of acute liver injury. Des is so minimally metabolized I usually think of it as un-metabolized, but it still has some toxic metabolites that can provoke the same antibody response that's behind halothane hepatitis. Here we've got a patient who had an episode of hepatitis immediately after anesthesia with desflurane. TIVAs are easy. I've done lots of TIVAs for weaker stories than this (funny family hx that smelled like it might possibly could've been MH).

Propofol? I just looked up a few case reports of hepatitis attributed to propofol. Two had symptoms present weeks later, not days. One was after an ERCP, ie a patient who had another reason to have an angry liver.
Click to expand...

You probably saw these, I excluded referencing the ERCP (for obvious reasons)

Case report #1 (Propofol only, presented back the next day with hepatitis)
Anand K, Ramsay MA, Crippin JS. Hepatocellular injury following the administration of propofol. Anesthesiology. 2001;95:1523–1524

Case report #2 (Colonoscopy, symptomatic 7 days later, presented to hospital 14 days later)
South Med J. 2009 Mar;102(3):333-4. doi: 10.1097/SMJ.0b013e318191c5ee.
 
I am interested in seeing her viral hepatitis serology results (A, B, and C) also if a liver ultrasound was done at that time.
It's highly unlikely that her hepatitis had anything to do with anesthesia.
maybe she got too much Tylenol after the Knee scope???
 
Mman said:
the only "likely" anesthetic cause of hepatitis would be halothane which has estimated incidence of fatal hepatitis of about 1:10,000 anesthetics and less than fatal probably far more often. Sevo or Des are almost impossible to get hepatitis from. Propofol? While metabolized hepatically it doesn't require much liver function at all to be cleared as every cirrhotics can metabolize it. There are a few case reports of acute hepatitis after propofol anesthesia but that is still extremely rare.
Click to expand...
Agreed, extremely rare incidence but described nonetheless. I personally have seen 3 cases of Sevo/des related hepatitis in the past 10yrs.
G0S2 said:
What kind of post op pain med was she on after knee scope?
Click to expand...
Typical kind. Lortab. Are you thinking what I'm thinking?
 
Planktonmd said:
I am interested in seeing her viral hepatitis serology results (A, B, and C) also if a liver ultrasound was done at that time.
It's highly unlikely that her hepatitis had anything to do with anesthesia.
maybe she got too much Tylenol after the Knee scope???
Click to expand...
Viral load nil
 
Noyac said:
Agreed, extremely rare incidence but described nonetheless. I personally have seen 3 cases of Sevo/des related hepatitis in the past 10yrs.

Typical kind. Lortab. Are you thinking what I'm thinking?
Click to expand...
Well... Lortab has Tylenol in it!
There are case reports of Tylenol induced Fulminant hepatitis after even small doses of Tylenol... way more common than Propofol induced idiopathic hepatitis.
 
Noyac said:
Middle aged female comes to pre-op clinic for interview prior to lumbar microdiscectomy. Mostly healthy, no meds, active. Long list of allergies of note though are Sevo and propofol.

History:
Pt has had many surgeries in the past but most recently had a knee scope under GA with Des and propofol for induction. 4 days later she was admitted to Hosp for acute hepatitis with elevated LFT's. ALT 2000, AST 800, ALK PHOS 500, INR 1.3. Pt c/o pruritis, nausea and loss of appetite. No other constitutional symptoms. Pt saw her primary who labeled her allergic to Sevo and propofol.
One year ago pt underwent colonoscopy with brevital without problems.

Today: she wants to have a microdiscectomy and refuses a spinal.

Plan?
Click to expand...


Honestly, I would discuss this plan with her:

I'm not convinced that the anesthesia caused your Liver problems. That said, I propose we avoid your "allergic drugs" and use Brevital, Midazolam and a Sufenta or Fentanyl Infusion for your case. In addition, I will place a BIS monitor on your forehead to help assist me in making certain you aren't awake during the procedure.

There is a small chance the breathing tube may be in place for up to 1 hour post procedure in the recovery room. The drugs I am using in place of your supposedly allergic ones stick around in the system longer so it may take an hour in the recovery room to get the breathing tube out.

Plan:

Brevital for Induction
Vecuronium or Rocuronium for single dose paralysis
Midazolam infusion vs Precedex Infusion with small doses of Midazolam IV as needed
Sufenta or Fentanyl Infusion
Bis Monitor (should be a short case)

I don't think Ketamine is needed here for the 1 hour case but I'd have it available in the room.
 
Out of principle:

It better not be "Sevo's" fault. :ninja:
 
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pgg said:
Yesterday I had a patient getting a laparoscopic diverting colostomy for a bowel obstruction. Allergic to fentanyl, morphine, codeine, hydromorphone, and 5 or 6 other drugs, tape too. She was getting Toradol for pain on the ward. I asked her what happened when she got fentanyl and she said "I died" ... tried to tease out exactly what happened and all I ever got out of her was "I died." No further details forthcoming. Frustrating. She wasn't demented. I did the case with ketamine, ketorolac, acetaminophen, magnesium, and no opiates.
Click to expand...

I love "allergies." I saw a propofol allergy one time, clicked on thinking it would be an egg allergy or something, and the description of the allergy was "stopped breathing." Priceless. Seen countless opioids that were something similar: stopped breathing, respiratory depression, etc. Saw one to naloxone that was "severe pain," lol.
 
My favorites are the allergies to epinephrine, steroids and antihistamines.
 
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FFP said:
My favorites are the allergies to epinephrine, steroids and antihistamines.
Click to expand...

Had a patient two days ago who said she was allergic to carbon dioxide. She said it would make her heart stop. She said if she drinks any sort of carbonated beverage (seltzer water included) her heart will immediately stop. No swelling, no rash, just death. She wouldn't elaborate on it any further, and I didn't push the issue. :laugh:
 
I am waiting for the ones allergic to water or oxygen. There is no limit to human stupidity, especially with the scientifically uneducated.
 
Had a lady (who wore pink fuzzy slippers into the hospital) w/over a dozen allergies. Insisted she was allergic to both diphenhydramine AND Benadryl, etc. She listed "bee stings" as an allergy - not for anaphylaxis, but rather for "pain, swelling, and local erythema".
 
Obviously, the answer is to use chloral hydrate and cyclopropane (with chloroform titrated as needed).

If she's allergic to those, you have a case report on your hands! (mostly 'cause no one has used them in a century.)
 
Noyac said:
Agreed, extremely rare incidence but described nonetheless. I personally have seen 3 cases of Sevo/des related hepatitis in the past 10yrs.

Typical kind. Lortab. Are you thinking what I'm thinking?
Click to expand...


Yes. Acetaminophen tox.
 
FFP said:
I am waiting for the ones allergic to water or oxygen. There is no limit to human stupidity, especially with the scientifically uneducated.
Click to expand...

I've had both. Well, technically the water one was saline, but still. The oxygen allergy was a nose bleed after several days of a nasal cannula. I didn't ask further about the saline. The ignorant can be taught, but stupid is forever.
 
Noyac said:
Anyone want to consider an US of the gall bladder?
Click to expand...

Maybe. LFTs' in the 1000's is not cholecystitis. That is more like a CBD problem. So if she is symptomatic, maybe an ERCP maybe the way to go.... although sometimes you can see a dilated CBD on USD... if the obstruction is big enough.
 
Follow up:
A most of you here, I suspected it was something other than the anesthetic that caused her hepatitis after the knee scope but since I have seen it occur from volatiles but never propofol I discussed with her what I thought was a good plan, spinal. It's only a microdiscectomy with a 1" incision at L4/5. She refused this plan and we discussed the odds of it being from the anesthetic. I felt like of anything the volatiles could have caused it so we proceeded with TIVA.

Move forward 5 days. She's back. Elevated enzymes, pruritis, loss of appetite, RUQ pain. Enzymes not as high this time 800's. Admitted for IV fluids and conservative care. I'M CONVINCED NOW! It is a propofol reaction. The first one I've ever seen but I've been doing this for over 10 yrs now and I guess I was bound to have one. Just like my MH case 2 yrs ago.

A week and a half later, she is home doing much better. This reaction takes weeks to resolve completely. They feel like crap for 4-6 weeks. It usually comes on 7-10 days post-op and is self limiting. Conservative treatment is usually all that is needed.

Those that said it was propofol, I looked back at your comments and got no real reason for your suspicion other than CYA. You guys were right to suspect it as I didn't give it much credit at the time. But the key in my mind is the delayed onset. I believe volatile induced hepatitis comes on sooner but I'd have to check on that one. I remember a pt returning a few days later after volatile agents cause hers. This one was 5 days after the knee scope so I didn't think it was propofol, expecting it to take longer. Well I learned that lesson.

What really sucks is that I was requested by the surgeon and the pt to do this case or else she wasn't going to have surgery. That sucks.
 
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Wow. This is a crazy case. Thanks for sharing. I learned something.
 
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