Thoughts on this case?

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amyl

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So a friend called me on my thoughts on this case... Wanted to see the consensus because we had different ideas. Morbidly obese woman w h/o cva and breast cancer s/p double mastectomy who's tissue expanded are now infected. Yesterday she had a stroke vs Tia - can't get the MRI bc of tissue expanders. How to proceed?
 
Forgot to add possible seizure with the cva/Tia. That's what I thought - infected.... Gotta get it out but another Anes wanted MAC and thought GA would kill her... I wasn't aware of Mac being safer than GA in post neuro-event period.
 
amyl said:
Forgot to add possible seizure with the cva/Tia. That's what I thought - infected.... Gotta get it out but another Anes wanted MAC and thought GA would kill her... I wasn't aware of Mac being safer than GA in post neuro-event period.
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MAC on infected tissue? Local is not going to work well.

Pent sux tube.

What's in the tissue expanders that prevents from doing a MRI?
 
I'm not sure the no MRI tissue expanders was a new one on me. Intact mental status. I'd make surgeon say it's an emergency and go but he consulted neuro who says highest re-event is 1-10 days can't you do antibiotics and wait. Geez
 
Learned something today. Thank you Amyl.

McGhan Medical Breast Tissue Expanders and MRI Issues. McGhan Medical Breast Tissue Expanders are intended for temporary subcutaneous implantation to develop surgical flaps and additional tissue coverage (Product Information documents, McGhan Medical/INAMED Aesthetics; Allergan, Inc.). These breast tissue expanders are constructed from silicone elastomer and consist of an expansion envelope with a textured surface, and a MAGNA-SITE integrated injection site. The expanders are available in a wide range of styles and sizes to meet diverse surgical needs. Specific styles include: Style 133 FV with MAGNA-SITE injection site, Style 133 LV with MAGNA-SITE injection site, Style 133 MV with MAGNA-SITE injection site, and Style 133 V with MAGNA-SITE injection site.

The MAGNA-SITE injection site and MAGNA-FINDER external locating device contain rare-earth, permanent magnets for an accurate injection system. When the MAGNA-FINDER is passed over the surface of the tissue being expanded, its rare-earth, permanent magnet indicates the location of the MAGNA-SITE injection site.

The Product Information documents for these breast tissue expanders states: “DO NOT use MAGNA-SITE expanders in patients who already have implanted devices that would be affected by a magnetic field (e.g., pacemakers, drug infusion devices, artificial sensing devices). DO NOT perform diagnostic testing with Magnetic Resonance Imaging (MRI) in patients with MAGNA-SITE expanders in place.”

Furthermore, in the Warnings section of the Product Information document, the following is indicated: “Diagnostic testing with Magnetic Resonance Imaging (MRI) is contraindicated in patients with MAGNA-SITE expanders in place. The MRI equipment could cause movement of the MAGNA-SITE breast tissue expander, and result in not only patient discomfort, but also expander displacement, requiring revision surgery. In addition, the MAGNA-SITE magnet could interfere with MRI detection capabilities.”

Therefore, MR procedures are deemed unsafe for patients with these specific breast tissue expanders.
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http://mrisafety.com/SafetyInfov.asp?SafetyInfoID=165
 
Get a CT scan to rule out hemorrhagic stroke (I assume this was already done). Did she get tPA? Have surgeon document urgency of case and get a neurologist to weigh in as well regarding neurologic risk (not that it would change management, but more to just cover bases). GA and keep BP relatively high (again assuming hemorrhagic infarct was ruled out). "Relatively high" would depend on what she's autoregulating at, but even that needs to be taken with a grain of salt since she may be septic.

My recipe would be etomidate, rocuronium, tube. I wouldn't use sux since she has a CVA from before as well (though admittedly we don't know if she has any deficits and if hyperkalemia is even an issue). Have pressor infusion ready. Extubate at end. Intact mental status preop indicates that her brain stem and frontal lobes are probably fine, meaning she shouldn't have a problem waking up and protecting her airway. How was the stroke/TIA diagnosed? Motor deficit? If so, more likely than not it was MCA territory, once again meaning it shouldn't affect your wake up and extubation.

MAC is just silly IMO.
 
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I agree Mac is silliness, like the last thing I'd do, which is why I posted this bc this other anes thought that was the only way to go. In general, I don't get why some people think Mac is less risky than GA. I doubt neuros plan of antibiotics to get her through the ten day window and then operating is going to work... Infected foreign bodies pretty much need to come out imho. She's stable, a febrile, no leukocytosis and neuro intact at the moment.... So better to operate now while she's stable or wait until she gets so bad that you have no choice? Then you add sepsis to the picture and she's likely to do worse....
 
Let's say you do an MRI and it shows multiple ischemic strokes or a brain tumor or whatever... are you then going to leave the infected expanders in place?
If the answer is no then GETA it is.
 
What about Mac v general for cysto/stent in septic pt? I feel that's a case where Mac is clearly better than geta. Probably because it's not very stimulating, v the expander removal example.
 
chmd said:
What about Mac v general for cysto/stent in septic pt? I feel that's a case where Mac is clearly better than geta. Probably because it's not very stimulating, v the expander removal example.
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The urologists I work with use a pretty big rigid scope. It seems to be pretty stimulating.
 
chmd said:
What about Mac v general for cysto/stent in septic pt? I feel that's a case where Mac is clearly better than geta. Probably because it's not very stimulating, v the expander removal example.
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The expander removal per se shouldn't be very stimulating either (it's right under the skin). What's stimulating is the debridement after, and God knows how long it takes, especially in the wrong hands.

I guess it could (not should) be done under MAC as an emergency (with the right anesthesiologist and the right surgeon), with removal of expanders, wound washout with antibiotics, left open to drain, daily washouts and GETA planned later (as tolerated) for final cleanup and debridement.

I occasionally do hemorrhoids under (propofol+fentanyl) deep MAC, even big painful ones, so it can be done. But only with the right surgeon.
 
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FFP said:
The expander removal per se shouldn't be very stimulating either (it's right under the skin). What's stimulating is the debridement after, and God knows how long it takes, especially in the wrong hands.

I guess it could (not should) be done under MAC as an emergency (with the right anesthesiologist and the right surgeon), with removal of expanders, wound washout with antibiotics, left open to drain, daily washouts and GETA planned later (as tolerated) for final cleanup and debridement.

I occasionally do hemorrhoids under (propofol+fentanyl) deep MAC, even big painful ones, so it can be done. But only with the right surgeon.
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What you are describing is not MAC, it's GA just without airway instrumentation.
 
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