ncdoc1974

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So you have a otherwise healthy G1P0 @32WGA posted for a lap chole secondary to cholecystitis/cholelithiasis...PreOp? Technique? Drugs? Monitoring? PostOp? Just a little discussion...
 

Noyac

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Wait till she delivers. But definitely can be done with minimal risks. Lap choles for the reasons you mentioned are not the type of surgeries that need to go now. Gall stone Pancreatitis is a risk but very low IMHO.
 
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ncdoc1974

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Wait till she delivers. But definitely can be done with minimal risks. Lap choles for the reasons you mentioned are not the type of surgeries that need to go now. Gall stone Pancreatitis is a risk but very low IMHO.
Good...so two days later it becomes evident she is developing gallstone pancreatitis and the general surgeon is now definitely wants to head to the OR...also over the past two days the patient has developed increasing SOB and you note a diastolic murmur in the holding room...O2 sats 91% on 2L O2 NC. FHR 140's and reactive...BP 138/79 HR 101 RR18....Now what?
 

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ARDS rearing its ugly head? OR time, before things get even worse.
Thio/sux/tube. Better have an a-line with your 2 large bore iv's.
And have OB immediately available if heart tones get scary.
 

Noyac

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ARDS rearing its ugly head? OR time, before things get even worse.
Thio/sux/tube. Better have an a-line with your 2 large bore iv's.
And have OB immediately available if heart tones get scary.
Not sure thats necessary. What are you going to run into in a healthy young pt with this situation that is going to require all that? I see gall stone pancreatitis once or twice a year and never is it a big issue but maybe our surgeons are on top of things better.

I would hope that the pt would have been watched pretty closely b/4 real problems arise. But if they need to go then you go to the OR and do the usual with the exception of fetal monitoring pre and post op.
 

Fastrach

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Not sure thats necessary. What are you going to run into in a healthy young pt with this situation that is going to require all that? I see gall stone pancreatitis once or twice a year and never is it a big issue but maybe our surgeons are on top of things better.

I would hope that the pt would have been watched pretty closely b/4 real problems arise. But if they need to go then you go to the OR and do the usual with the exception of fetal monitoring pre and post op.
Odds are you're right, Noy, but I'm just anticipating since they bothered to post it, this case is gonna go to hellinahandbasket... bring on the DIC! ;)
 

dhb

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ERCP anyone?

diastolic murmurs aren't good, i'd like to see an echo. she has to go to sleep anyhow....
 

ncdoc1974

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ERCP anyone?

diastolic murmurs aren't good, i'd like to see an echo. she has to go to sleep anyhow....
Would you delay the case for the echo? Even without an echo, is an a-line necessary?

(Note: this is not actually a "real" case, but it could be--just trying to generate some discussion for those who are interested)
 

Planktonmd

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The diastolic murmur is indeed worrisome.
Endocarditis and acute aortic regurgitation??
You shouldn't have waited :D
 

ncdoc1974

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The diastolic murmur is indeed worrisome.
Endocarditis and acute aortic regurgitation??
You shouldn't have waited :D
Very good...so an echo was done and the patient has developed aortic regurgitation possibly from endocarditis...(definite AR on the TTE, but suboptimal view of the aortic valve leaflets, unable to clearly view any vegitations, pt. is afebrile currently but has been on antibiotics started by the general surgeon, and you also note the patient has received 5 liters of IVF over the last 48 hours) Now what? How would you proceed? And what about the baby in light of the possible endocarditis?
 

Noyac

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Very good...so an echo was done and the patient has developed aortic regurgitation possibly from endocarditis...(definite AR on the TTE, but suboptimal view of the aortic valve leaflets, unable to clearly view any vegitations, pt. is afebrile currently but has been on antibiotics started by the general surgeon, and you also note the patient has received 5 liters of IVF over the last 48 hours) Now what? How would you proceed? And what about the baby in light of the possible endocarditis?
Now you tapping into the recesses of my mind.

Off the top of my head, start steroids for fetal lung maturity however, this may worsen the infection but unlikely. This baby is probably going to be born real soon. Get a TEE for a better look at the valves but honestly it doesn't matter that much since this pt will declare herself real soon.

So I assume you are saying that this pt has an infected gall bladder which has seeded her AV. Her AR will worsen the closer to term she gets and she will probably need a valve replacement b/4 that so stabilize her with the plan of taking her to the OR for combo c/s AVR. Get the fetus ready for cesarean and after the baby is out and uterus closed, do the valve replacement.

Is that where you are headed with this?
 

Planktonmd

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Very good...so an echo was done and the patient has developed aortic regurgitation possibly from endocarditis...(definite AR on the TTE, but suboptimal view of the aortic valve leaflets, unable to clearly view any vegitations, pt. is afebrile currently but has been on antibiotics started by the general surgeon, and you also note the patient has received 5 liters of IVF over the last 48 hours) Now what? How would you proceed? And what about the baby in light of the possible endocarditis?
This is still a hypothetical case isn't it??
At this point patient has acute AR with fluid overload and in pulmonary edema so let's treat that first: Diuretics, afterload reduction, oxygen...
Send a few blood cultures and start ATBX covering gram positive and negative.
Put her to sleep and remove gall bladder and baby.
Aortic valve replacement to be considered later.
 
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Gator05

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This is still a hypothetical case isn't it??
At this point patient has acute AR with fluid overload and in pulmonary edema so let's treat that first: Diuretics, afterload reduction, oxygen...
Send a few blood cultures and start ATBX covering gram positive and negative.
Put her to sleep and remove gall bladder and baby.
Aortic valve replacement to be considered later.
Agree agree agree, although some of the fluid overload will get better with a slightly messy c-section. And I'd advocate for baby, then gall bladder.

Would anyone consider doing the section under spinal, then convert to GA for the lap chole? Or spinal for the section, then possible ERCP? I must say, I'm not real crazy about insufflating the belly peripartum of a woman with symptomatic AR.

I'd want to look at the echo again after baby is out. Not sure how wise it is to base a replace/repair decision with pregnant hemodynamics. Reeval the Ao valve issue after delivery.

Oh, and I'd feel much better if the TEE machine was parked outside for all of this.
 

toughlife

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Would you delay the case for the echo? Even without an echo, is an a-line necessary?

(Note: this is not actually a "real" case, but it could be--just trying to generate some discussion for those who are interested)
Yes, because a diastolic murmur can represent AR or MS and pt is desatting and dyspneic which can also be c/w HF d/t MS. Based on the history we know what's going on now, but initially we would have to be thorough and consider all possibilities. So yeah, I would put an a-line.
 

dhb

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The clinical picture doesn't fit: she's developing an acute endocarditis with AI in 2 days while being afebrile and on atbx?
Could it be a pregnancy related cardiomyopathy?

i'd still go with an ERCP especially since the cholecystitis seems to be controled.
 

Noyac

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The clinical picture doesn't fit: she's developing an acute endocarditis with AI in 2 days while being afebrile and on atbx?
Could it be a pregnancy related cardiomyopathy?

i'd still go with an ERCP especially since the cholecystitis seems to be controled.
It's possible that the antbx are keeping the fevers down but that the vegetations on the valve are present and causing a real problem. I'm pretty sure once the valves have vegetations enough to cause sev. AI that the treatment is AVR.
 

ncdoc1974

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This is still a hypothetical case isn't it??
At this point patient has acute AR with fluid overload and in pulmonary edema so let's treat that first: Diuretics, afterload reduction, oxygen...
Send a few blood cultures and start ATBX covering gram positive and negative.
Put her to sleep and remove gall bladder and baby.
Aortic valve replacement to be considered later.
Yes, this is still a hypothetical case...I am enjoying the banter...I am personally with Planktonmd on this one...we are not 100% sure about the etiology of the AR at this point and I think getting the baby and gall bladder out under GA at this point would probably be the right move...I would probably place an aline pre-op mainly because of the oddity of this case and uncertainty of the hemodynamic swings that could occur. I would not necessarily fault anyone for not placing an aline, but I have a feeling if I didn't place one I might be kicking myself in the middle of the case...I would not expect to do an AVR immediately...I would probably try to delay this procedure if at all possible...Does anyone really want to give 30,000 units of heparin to a lady 15 min after a C/S?????
 

dhb

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It's possible that the antbx are keeping the fevers down but that the vegetations on the valve are present and causing a real problem. I'm pretty sure once the valves have vegetations enough to cause sev. AI that the treatment is AVR.
what i'm questioning is can this occur in a couple of days? could there be another etiology?
 

Planktonmd

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what i'm questioning is can this occur in a couple of days? could there be another etiology?
We don't know for how long she had an infection before someone suspected biliary etiology. Also we were told that she is afebrile now but we don't know if she was afebrile before.
If you are suspecting a pregnancy induced cardio myopathy how do you explain the diastolic murmur? Is it a pre existing problem?
Not that many healthy young women walk around with diastolic murmurs.
Although this case is obviously a zebra made up by the OP It does bring up many interesting issues.
 

militarymd

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are we don't spanking it yet?
 

militarymd

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Hey, The guy said it is a hypothetical case for discussion, this means it is purely for spanking (it) purposes.
I actually think this is a great "spanking it" opportunity that you might want to give it a shot.

ok

treatment for gallstone pancreatitis is not cholecystectomy...it is ERCP.

As for the gall bladder..

1) not sick....go to sleep...regurgitant lesions don't kill patients in the OR
2) sick ...per drain....regurgitant lesions don't kill patients in special procedures.


all those other studies....order them if you want, but you're just wasting time.... you guys aren't CArds, ID, or whatever...

just put them to sleep.
 

Planktonmd

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ok

treatment for gallstone pancreatitis is not cholecystectomy...it is ERCP..
I didn't think she had pancreatitis did he say that?
If she has a gangrenous gall bladder that has caused an endocarditis it needs to come out and you could do an intraop common duct exploration.


As for the gall bladder..

1) not sick....go to sleep...regurgitant lesions don't kill patients in the OR
2) sick ...per drain....regurgitant lesions don't kill patients in special procedures.


all those other studies....order them if you want, but you're just wasting time.... you guys aren't CArds, ID, or whatever...

just put them to sleep.
Fair enough.
 

coprolalia

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Lap chole? Lap chole? LAP chole? As in LAPAROSCOPIC? At 32 weeks EGA?
You dudes have some seriously ballsy general surgeons at your institutions.

-copro
 

Noyac

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ok

treatment for gallstone pancreatitis is not cholecystectomy...it is ERCP.

As for the gall bladder..

1) not sick....go to sleep...regurgitant lesions don't kill patients in the OR
2) sick ...per drain....regurgitant lesions don't kill patients in special procedures.


all those other studies....order them if you want, but you're just wasting time.... you guys aren't CArds, ID, or whatever...

just put them to sleep.

What do you want to do about the vegetations on the aortic valve?
 

coprolalia

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You guys are WAY overintellectualizing this:

1) Betamethasone for baby lungs. A 32-weeker is easily viable.
2) Get the goddamn baby out.
3) Take the GB out BEFORE she gets ascending cholangitis.
4) Everyone goes home happy.

There. Done. End of discussion.

-copro
 

Planktonmd

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This is still a hypothetical case isn't it??
At this point patient has acute AR with fluid overload and in pulmonary edema so let's treat that first: Diuretics, afterload reduction, oxygen...
Send a few blood cultures and start ATBX covering gram positive and negative.
Put her to sleep and remove gall bladder and baby.
Aortic valve replacement to be considered later.
You guys are WAY overintellectualizing this:

1) Betamethasone for baby lungs. A 32-weeker is easily viable.
2) Get the goddamn baby out.
3) Take the GB out BEFORE she gets ascending cholangitis.
4) Everyone goes home happy.

There. Done. End of discussion.

-copro
Yes.
 
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