Severe Hypotension During Lumbar Fusion Surgery

[deleted171991]

Can you expound a bit on how you think about base excess vs. lactate as indicators in this situation? They often track together but I have no doubt there's specific reasons each may be better for different cases.

In this situation, lactate is irrelevant due to epi administration. And BE should have been irrelevant for about 70 years, since it was invented.

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[Psai]

In this situation, lactate is irrelevant due to epi administration. And BE should have been irrelevant for about 70 years, since it was invented.

Base excess is useful for figuring out who is worth listening to.

 

[Noyac]

We typically withhold comment on moderator actions, but in this case I'll just say that bans, except for newly registered obvious troll accounts, usually aren't done because of a single post. General posting history, previous warnings, and (least obviously visible of all) connections to other accounts with trollish histories factor in. Often we don't make the forensic connections between an old troll and an innocent seeming account until it catches our attention for something less innocent.

As a rule we don't just ban nurses for being nurses, or stating true things that make us look deservedly bad. Long history however has given us a short fuse to move CRNAs who come here to educate us up the warn/ban ladder.

I assume you are writing this for others to benefit from since you must know, I am extremely clear on these issues. I will admit that I haven’t looked at the banned posters previous post but the one I did read doesn’t warrant the banning IMO. And as a past mod here, I feel more than qualified to make this observation.

 

[Noyac]

Base excess is useful for figuring out who is worth listening to.

Yeah yeah, I’m old I get it.

 

[pgg]

I assume you are writing this for others to benefit from since you must know, I am extremely clear on these issues. I will admit that I haven’t looked at the banned posters previous post but the one I did read doesn’t warrant the banning IMO. And as a past mod here, I feel more than qualified to make this observation.

OK.

 

[propadope]

How does an anesthesiologist take 30 minutes to notice that the patient doesn't have a blood pressure?

I hope he got fired and stripped of his license. Embarrassing.

Must have been stuck on a crossword clue

 

[deleted171991]

Must have been stuck on a crossword clue

No. He was busy adjusting the table.

 

[Arch Guillotti]

No. He was busy adjusting the table.

No way. Definitely sudoku.

 

[sevoflurane]

Interesting case. Thank you for sharing.
I’ve never used a Wilson frame before.
It’s a tough crowd here sometimes. Keep your chin up and thank you for your case presentation.

Cheers,

Sevo

 

[Twiggidy]

No way. Definitely sudoku.

Pornhub

 

[propadope]

Pornhub

I’ve never looked at Pornhub for more than 5 minutes

 

[Twiggidy]

I’ve never looked at Pornhub for more than 5 minutes

i see what you're doing there....

 

[pgg]

i see what you're doing there....

I'd rather not

 

[Psai]

I’ve never looked at Pornhub for more than 5 minutes

That's like 4 minutes too much

 

[Twiggidy]

I'd rather not

this is true.......although ........Propadope could be some Instagram model......

 

[vector2]

*looks into crystal ball*

*sees our forum rapidly approaching singularity where all threads are either about pornhubbing during slow intraop codes or googling NPO semen times*

 

[deleted162650]

*looks into crystal ball*

*sees our forum rapidly approaching singularity where all threads are either about pornhubbing during slow intraop codes or googling NPO semen times*

The two are not necessarily mutually exclusive.

 

[Noyac]

Now the last few posts are more worthy of banning than the crna’s Post.

Just saying.

 

[sigrhoillusion]

No way. Definitely sudoku.

I feel that I'm pretty good at puzzles, but I always feel like with harder Soduku puzzles, you inherently have to guess at some point...

Also, in response to the table comment, I remember a surgeon who worked at the hospital I trained at, who was ridiculous with his positioning requests. Every 10 seconds he needed a table adjustment. We used to joke that he just stood there with the scalpel facing downwards and just had us move the patient around to do all the cutting...

 

[GravelRider]

*looks into crystal ball*

*sees our forum rapidly approaching singularity where all threads are either about pornhubbing during slow intraop codes or googling NPO semen times*

6 hours

 

[IlDestriero]

Had this happen in residency, scoliosis surgery in an OTW healthy young person, Wilson frame, refractory hypoTN caused by reduced VR, ended up with anoxic brain injury

I’ve had a few prone cases where the BP tanked unexpectedly and didn’t rapidly respond to fluids and pressors. 2 were shortly after the flip. One responded quickly to an adequate BP but on essentially no anesthetic, pressors and 60/kg fluid bolus. Checked positioning, not obese, didn’t seem to have abd compression, etc. though that was a possible diagnosis after hypovolemia was addressed. He had some other issues as well that could have been contributing. Repositioned supine and didn’t rebound quickly as expected either. Cancelled, $1M work up all negative, back in a couple weeks, prehydrated, no problems. Still not sure what happened there.
Obese guy completely tanked when prone, flipped supine rapidly recovered, surgeon cancelled and said too obese, lose weight or find another surgeon. Hero status was earned there. Last one was 2/3 of the way through a longer spinal fusion. That was probably air embolism/microembolism/etc. Pressors, epi and fluids/blood were only temp bandaids, getting progressively worse as interventions escalated. Turned supine after 3 layers of ioban over his open back, rapid recovery. Rapid recovery of crappy gas, surgeon finished the case lateral without any further hypotension. Extra dose of ancef. Not ideal, but he did it and it worked fine.
Not to pile on, but with the gasses and numbers you quoted above, I would have exercised the nuclear option way, way, way earlier and gone at least lateral to see if it resolved the potentially catastrophic hypotension and hypoperfusion.
I can’t imagine a surgeon wanting to continue with labs and vitals like that. Battle field salvage time and GTFO so they live to go back for stage 2 to finish the job.
Ignoring or failing to promptly correct significant or worsening hypotension is Russian roulette with your patient’s vital organs. I’m sure the lactate they ordered in the ICU was impressive.

 

[Psai]

Actually now that I think about it, I also had a case on a wilson frame where we had hypotension that needed increasing pressor and a significant amount of fluid. I remember being surprised at how much was necessary despite the low blood loss.

 

[drmwvr]

Yeah yeah, I’m old I get it.

A base excess on a gas slip is like your wife telling you that you drank too much the night before. Nothing you don't already know, but it adds a little antagonism to the situation. Not going to do anything differently, just with a little more discretion...

 

[neutro]

interesting.

Shows you that despite best efforts and thorough analysis of situation and presenting appropraite differential diagnoses, sometimes, unexplainable clinical picture presents itself where it is nearly impossible to figure out the solution right away. It is very vague and the focus then needs to be on management...

 

[drmwvr]

interesting.

Shows you that despite best efforts and thorough analysis of situation and presenting appropraite differential diagnoses, sometimes, unexplainable clinical picture presents itself where it is nearly impossible to figure out the solution right away. It is very vague and the focus then needs to be on management...

Acidemia/acidosis are/is what they are/is...in the operating room these phenomenon are not vague,obtuse or elusive. They have an identifiable cause and immediate treatment in 99% of cases. Very rare that this is not the case. Am I misunderstanding?

 

[neutro]

Acidemia/acidosis are/is what they are/is...in the operating room these phenomenon are not vague,obtuse or elusive. They have an identifiable cause and immediate treatment in 99% of cases. Very rare that this is not the case. Am I misunderstanding?

99% of the time only... hah

yes of course acidosis would cause myocardial depression and subsequent HoTN, esp. if ph < 7.2, and you can treat that acidosis all you want, but if the problem is hypoventilation due to the tight frame because of patient specific positioning/ anatomy or the way they are "seated" on the frame, you will not fix anything until she is off the frame, as it was in this case.
I would not expect every patient with BMI 42 to have difficulty ventilating on a spine frame, esp 45 minutes into the case. In fact BMI of 42 is run of the mill where I practice and I am sure it is for you also, and we do not run into hypotension just because they are obese and on a frame...

 

[Noyac]

A base excess on a gas slip is like your wife telling you that you drank too much the night before. Nothing you don't already know, but it adds a little antagonism to the situation. Not going to do anything differently, just with a little more discretion...

Base Excess is an anachronism for sure. But it is still a key parameter for diagnosing metabolic derangement in acid base status.

 

[deleted697127]

I’ve had a few prone cases where the BP tanked unexpectedly and didn’t rapidly respond to fluids and pressors. 2 were shortly after the flip. One responded quickly to an adequate BP but on essentially no anesthetic, pressors and 60/kg fluid bolus. Checked positioning, not obese, didn’t seem to have abd compression, etc. though that was a possible diagnosis after hypovolemia was addressed. He had some other issues as well that could have been contributing. Repositioned supine and didn’t rebound quickly as expected either. Cancelled, $1M work up all negative, back in a couple weeks, prehydrated, no problems. Still not sure what happened there.
Obese guy completely tanked when prone, flipped supine rapidly recovered, surgeon cancelled and said too obese, lose weight or find another surgeon. Hero status was earned there. Last one was 2/3 of the way through a longer spinal fusion. That was probably air embolism/microembolism/etc. Pressors, epi and fluids/blood were only temp bandaids, getting progressively worse as interventions escalated. Turned supine after 3 layers of ioban over his open back, rapid recovery. Rapid recovery of crappy gas, surgeon finished the case lateral without any further hypotension. Extra dose of ancef. Not ideal, but he did it and it worked fine.
Not to pile on, but with the gasses and numbers you quoted above, I would have exercised the nuclear option way, way, way earlier and gone at least lateral to see if it resolved the potentially catastrophic hypotension and hypoperfusion.
I can’t imagine a surgeon wanting to continue with labs and vitals like that. Battle field salvage time and GTFO so they live to go back for stage 2 to finish the job.
Ignoring or failing to promptly correct significant or worsening hypotension is Russian roulette with your patient’s vital organs. I’m sure the lactate they ordered in the ICU was impressive.

I’m imagining a surgeon telling a 12 year old he’s too fat and to find another surgeon.

 

[fakin' the funk]

We speculate that the Wilson frame combined with the obesity caused compression with a significant decrease in cardiac venous return with life threatening hypotension and when a different frame was chosen, there was no such complication.

Late to the party here, but yeah, life threatening hypotension 10 minutes into a prone case merits pausing, discussing aborting the case, and considering flipping supine ASAP.

Did anyone speculate that the frame+obesity combo was the culprit DURING the case? Because I speculated the position/table was involved based on the title of this thread.