Unable to drain belly prior to surgery in PD patient...??

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Hoya11

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46 year old lady. Morbidly Obese. HTN. IDDM. BMI 50. Lives in facility, fell, broke left ankle also has necrotic left middle toe. Creatinine 10. INR 1.2. All other labs relatively normal. Normal EF with mild diastolic dysfunction.

Long story short, she also has ESRD secondary to IDDM and HTN and has been on PD for years. She is called for to come down from the floor and the nurse tells the CRNA that she just had dialysate put in her belly. The CRNA says to stop PD and drain the belly prior to surgery. So, I call the floor.

I talk to the renal attending. He says her belly is ALWAYS full. Either with waste or with dialysate. And her PD is not to be interrupted. I say, well If I were to wait, when would be a possible time that her belly could be drained and she would have a normal peritoneal cavity. His answer is never, she always has either waste or dialysate in her belly and its never empty. She gets 6 treatments a day. 0

So now the foot is infected and toe is gangrenous and its semi-urgent. So I end up doing the case under epidural which was minorly technically challenging, but after the catheter was in she did beautifully. IT was a 2.5 hour case and she did well with 2mg midaz and 50 fent in addition to about 35cc of 2% lido. I pulled the catheter at the end after a bolus of 5cc 0.25% bupi for recovery period.

So about 6 hours later at midnight im called for code blue, its her, shes unresponsive 30 mins after 5mg morphine by floor RN. Responds to narcan, throws up multiple times all over me but protects her airway, is transferred to unit and started on narcan gtt and does well back to baseline.

This was really an interesting case for me because I dont know that much about PD, and I dont understand how someone can live life with a full belly ALL the time that cant be drained for semi-urgent surgery? Was I lied to by the renal attending? These patients obviously are very fragile as she coded after 5 of morphine on the floor and Im glad I choose epidural, but I have never encountered one who has to CONSTANTLY have a full belly and is at huge risk for these complications.. thought?? thanks
 
I've never seen someone that needs PD that has to be constantly in and out and is never empty... if they're so inefficient to the point that they need 6 treatments a day, I would think HD would be the way to go. But I'm not the kidney guy...

I think you did as good of a job managing this case as you could have.

One last thought... morphine for a morbidly obese ESRD patient?
 
One last thought... morphine for a morbidly obese ESRD patient?



YIKES[/QUOTE]

ya thats the kind of care you get at my hospital on the floor, its scary, we serve a mostly low income population and hence nurses are mostly left overs
 
Hoya11 said:
46 year old lady. Morbidly Obese. HTN. IDDM. BMI 50. Lives in facility, fell, broke left ankle also has necrotic left middle toe. Creatinine 10. INR 1.2. All other labs relatively normal. Normal EF with mild diastolic dysfunction.

Long story short, she also has ESRD secondary to IDDM and HTN and has been on PD for years. She is called for to come down from the floor and the nurse tells the CRNA that she just had dialysate put in her belly. The CRNA says to stop PD and drain the belly prior to surgery. So, I call the floor.

I talk to the renal attending. He says her belly is ALWAYS full. Either with waste or with dialysate. And her PD is not to be interrupted. I say, well If I were to wait, when would be a possible time that her belly could be drained and she would have a normal peritoneal cavity. His answer is never, she always has either waste or dialysate in her belly and its never empty. She gets 6 treatments a day. 0

So now the foot is infected and toe is gangrenous and its semi-urgent. So I end up doing the case under epidural which was minorly technically challenging, but after the catheter was in she did beautifully. IT was a 2.5 hour case and she did well with 2mg midaz and 50 fent in addition to about 35cc of 2% lido. I pulled the catheter at the end after a bolus of 5cc 0.25% bupi for recovery period.

So about 6 hours later at midnight im called for code blue, its her, shes unresponsive 30 mins after 5mg morphine by floor RN. Responds to narcan, throws up multiple times all over me but protects her airway, is transferred to unit and started on narcan gtt and does well back to baseline.

This was really an interesting case for me because I dont know that much about PD, and I dont understand how someone can live life with a full belly ALL the time that cant be drained for semi-urgent surgery? Was I lied to by the renal attending? These patients obviously are very fragile as she coded after 5 of morphine on the floor and Im glad I choose epidural, but I have never encountered one who has to CONSTANTLY have a full belly and is at huge risk for these complications.. thought?? thanks
Click to expand...

if she is getting constant PD the volume is likely relatively low ie 2 liters and in a morbidly obese patient ie huge compliant belly this is unlikely to have major consequence especially given that the pt is well-acclimated to the PD volumes.

my question - why the hell did you pull the epidural? could've avoided primary team morphine postop for days and avoided vomitus on your scrubs...

if your answer is that you didn't think she'd have much pain postop given decreased sensation from IDDM then mebbe you should have just done an ankle block (all this assuming that they just did amputation/debridement and postponed ORIF of ankle for another day) bmi of 50 isn't that big in my book...
 
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ya thats the kind of care you get at my hospital on the floor, its scary, we serve a mostly low income population and hence nurses are mostly left overs[/QUOTE]


Presumably someone thought it was an ok medication/dose and ordered it before it was given.
 
nap$ter said:
if she is getting constant PD the volume is likely relatively low ie 2 liters and in a morbidly obese patient ie huge compliant belly this is unlikely to have major consequence especially given that the pt is well-acclimated to the PD volumes.

my question - why the hell did you pull the epidural? could've avoided primary team morphine postop for days and avoided vomitus on your scrubs...

if your answer is that you didn't think she'd have much pain postop given decreased sensation from IDDM then mebbe you should have just done an ankle block (all this assuming that they just did amputation/debridement and postponed ORIF of ankle for another day) bmi of 50 isn't that big in my book...
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no its because they dont take epidurals on the floor, and when you send someone to the unit with an epidural its non-stop pages, like i said not the cream of the crop place, they freak out when there are thoracic epidurals after thoracotomy. overall frequency of epidurals in the hospital in general is about 1-2 every 2-3 months (and there mostly mine)! im trying to change this culture, being a pain guy. Because there are plenty of surgeries that warrant them, but due to surgeon refusal (insane), pharmacy confusion (so you want bupivicaine in a bag? how should i mix it?) i pulled it. i would have loved to leave it in and run a dilute infusion but then there would have been freak out, and at 1/8% this lady would have still complained of pain and same events happen plus the pages about the epidural and then blaming the epidural for any complications as opposed to the morphine. it was even raised during the code that the epidural (Which was removed 6 hrs prior to the event) was responsible, as opposed to the morphine, this is the kind of place im at, the next person below me on the totem pole is a PA covering the whole ICU who is about 25 and started within the year, nice guy, but not competent for complex stuff. so i pulled it to keep it simple. im not convinced an infusion in the ICU would have prevented the morphine bolus. And who orders the morphine bolus? the ortho PA of course. A big problem in general at my hospital is that low or mid level practitioners make very important decisions in complex patients. There was actually a death because someone got the bright idea to put multiple tunneled catheters in place for a burn patient, and the pharmacy mixed 0.5% bupivicaine at 14ml/hr into multiple sites and the patient died, this was within last two years, still gun shy about local anesthetic and catheters after that (not my case of course). NO Peripheral nerve catheters are done. SO its not like i exactly have everything at my control there are system issues i have to deal with, obviously resulting in a less than ideal post-op course. She was also sick in the kind of way that she had mysteriously fluctuationg INRs, no AC meds, but it was 2.3 one month ago, on recheck it was 1.2 so i went ahead, but i wanted the catheter out while the numbers looked good.

But anyway, back to my question, so I guess continuous belly full of fluid is a thing? THe main concern I have is that I did not take a strong enough stance on having her belly drained, and dont get me wrong i got around it using regional, but did I need to? I couldnt believe he told me I couldnt drain it...What difference could it possibly make vs the potential anesthetic risks. And I think she vomitted in part becuase of her full extraperitoteanl space compressing her most recent meal, so I think the full belly made her significantly more risk for aspiration and if on MV im certain we'd see high PIPs limiting ventilation. And yes it was an ORIF, long and brutal.
 
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diabetic with ESRF needing foot surgery = ankle block +/- propofol TCI
you just need to augment their neuropathy
 
Hoya11 said:
no its because they dont take epidurals on the floor, and when you send someone to the unit with an epidural its non-stop pages, like i said not the cream of the crop place, they freak out when there are thoracic epidurals after thoracotomy. overall frequency of epidurals in the hospital in general is about 1-2 every 2-3 months (and there mostly mine)! im trying to change this culture, being a pain guy. Because there are plenty of surgeries that warrant them, but due to surgeon refusal (insane), pharmacy confusion (so you want bupivicaine in a bag? how should i mix it?) i pulled it. i would have loved to leave it in and run a dilute infusion but then there would have been freak out, and at 1/8% this lady would have still complained of pain and same events happen plus the pages about the epidural and then blaming the epidural for any complications as opposed to the morphine. it was even raised during the code that the epidural (Which was removed 6 hrs prior to the event) was responsible, as opposed to the morphine, this is the kind of place im at, the next person below me on the totem pole is a PA covering the whole ICU who is about 25 and started within the year, nice guy, but not competent for complex stuff. so i pulled it to keep it simple. im not convinced an infusion in the ICU would have prevented the morphine bolus. And who orders the morphine bolus? the ortho PA of course. A big problem in general at my hospital is that low or mid level practitioners make very important decisions in complex patients. There was actually a death because someone got the bright idea to put multiple tunneled catheters in place for a burn patient, and the pharmacy mixed 0.5% bupivicaine at 14ml/hr into multiple sites and the patient died, this was within last two years, still gun shy about local anesthetic and catheters after that (not my case of course). NO Peripheral nerve catheters are done. SO its not like i exactly have everything at my control there are system issues i have to deal with, obviously resulting in a less than ideal post-op course. She was also sick in the kind of way that she had mysteriously fluctuationg INRs, no AC meds, but it was 2.3 one month ago, on recheck it was 1.2 so i went ahead, but i wanted the catheter out while the numbers looked good.

But anyway, back to my question, so I guess continuous belly full of fluid is a thing? THe main concern I have is that I did not take a strong enough stance on having her belly drained, and dont get me wrong i got around it using regional, but did I need to? I couldnt believe he told me I couldnt drain it...What difference could it possibly make vs the potential anesthetic risks. And I think she vomitted in part becuase of her full extraperitoteanl space compressing her most recent meal, so I think the full belly made her significantly more risk for aspiration and if on MV im certain we'd see high PIPs limiting ventilation
Click to expand...

wow.

hope you have a most excellent reason for working in a goat rodeo like that.

knowing all of the above i woulda either arranged to put her in the unit with an epidural or ankle block/propofol or if not truly neuropathic saph/sciatic blocks c decadron (in my humble experience perineural decadron doesn't do much to blood sugars). if you can't prevent morphine boluses in the ICU with an order when running an epidural i would leave that position - you are being put at unnecessary risk for litigation.

the big fault was with the ortho PA, but we don't have al the details on that either. i would guess she was getting morphine preop on the floor as well.
 
I would have performed an U/S Popliteal block with 0.5% Bup plus decadron for the case. An epidural was reasonable but seems like overkill for a necrotic toe. In addition, the Popliteal block would have lasted for more than 24 hours.

The fact the patient complained of pain on the floor is proof she had some (a lot?) of sensation to her foot warranting a long acting block for postop pain relief.

The OP handled the case reasonably well and I agree that the belly should have been decompressed prior to the case. My group performs thousands of anesthetics on renal failure patients each year (yes, thousands) and I have never encountered one as described by the OP. Perhaps, the patient also had liver disease/failure?

In my practice I avoid Neuraxial anesthesia in this subgroup of patients for minor procedures and prefer regional extremity blocks.
 
Hoya11 said:
no its because they dont take epidurals on the floor, and when you send someone to the unit with an epidural its non-stop pages, like i said not the cream of the crop place, they freak out when there are thoracic epidurals after thoracotomy. overall frequency of epidurals in the hospital in general is about 1-2 every 2-3 months (and there mostly mine)! im trying to change this culture, being a pain guy. Because there are plenty of surgeries that warrant them, but due to surgeon refusal (insane), pharmacy confusion (so you want bupivicaine in a bag? how should i mix it?) i pulled it. i would have loved to leave it in and run a dilute infusion but then there would have been freak out, and at 1/8% this lady would have still complained of pain and same events happen plus the pages about the epidural and then blaming the epidural for any complications as opposed to the morphine. it was even raised during the code that the epidural (Which was removed 6 hrs prior to the event) was responsible, as opposed to the morphine, this is the kind of place im at, the next person below me on the totem pole is a PA covering the whole ICU who is about 25 and started within the year, nice guy, but not competent for complex stuff. so i pulled it to keep it simple. im not convinced an infusion in the ICU would have prevented the morphine bolus. And who orders the morphine bolus? the ortho PA of course. A big problem in general at my hospital is that low or mid level practitioners make very important decisions in complex patients. There was actually a death because someone got the bright idea to put multiple tunneled catheters in place for a burn patient, and the pharmacy mixed 0.5% bupivicaine at 14ml/hr into multiple sites and the patient died, this was within last two years, still gun shy about local anesthetic and catheters after that (not my case of course). NO Peripheral nerve catheters are done. SO its not like i exactly have everything at my control there are system issues i have to deal with, obviously resulting in a less than ideal post-op course. She was also sick in the kind of way that she had mysteriously fluctuationg INRs, no AC meds, but it was 2.3 one month ago, on recheck it was 1.2 so i went ahead, but i wanted the catheter out while the numbers looked good.

But anyway, back to my question, so I guess continuous belly full of fluid is a thing? THe main concern I have is that I did not take a strong enough stance on having her belly drained, and dont get me wrong i got around it using regional, but did I need to? I couldnt believe he told me I couldnt drain it...What difference could it possibly make vs the potential anesthetic risks. And I think she vomitted in part becuase of her full extraperitoteanl space compressing her most recent meal, so I think the full belly made her significantly more risk for aspiration and if on MV im certain we'd see high PIPs limiting ventilation. And yes it was an ORIF, long and brutal.
Click to expand...

I never understood that why mid levels get labels like ortho pa or derm np. It's not like they get any sort of extra training from which they earned such a designation
 
lowerlimb-fig8-small.jpg
 
If she is getting PD that consistently then she needs to be reassessed for HD. PD patients can develop peritoneal fibrosis after long term PD and some of the classic signs of this are poor PD efficiency. So if she is constantly putting fluid in and taking it out and needs to do this to maintain herself then it's lilely become a very inefficient filtration. Your renal doc sounds like a *****. You could easily have drained her, done the case, then filled her in the PACU.
 
http://www.nature.com/ki/journal/v68/n5/full/4496386a.html


Background

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). It is characterized by a progressive, intra-abdominal, inflammatory process resulting in sheets of fibrous tissue that cover, bind, and constrict the viscera, thereby compromising the motility and function of the bowel. Although recent therapeutic approaches have been reported with variable success, the ability to detect reliably at an early stage patients at risk for EPS would be beneficial and allow treatment standardization. The aim of this study was to evaluate the clinical features of EPS and identify possible risk factors for its development in CAPD and APD patients.

Methods

This was a review of all cases of EPS in a single center over the last 5 years.

Results

There were 810 CAPD and APD patients, managed in our program over this period. We identified 27 cases of EPS, giving an overall of 3.3% in this population. The mean duration of CAPD before diagnosis of EPS was 72.6
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39.7 months (range 16–172). Sixteen cases required surgical treatment and were classified as severe; others were treated conservatively (mild to moderate group). Ten patients received tamoxifen treatment with apparent benefit. The overall mortality rate was 29.6%. Eight patients from the severe group and the entire moderate group survived on hemodialysis or transplantation at 48.71 and 27.63 months follow-up, respectively. Peritonitis rates were not different between the 2 groups and peritoneal history was unremarkable compared to overall peritonitis rates in the unit. Data on small solute transport were not available in all patients in this retrospective analysis.

Conclusion

EPS is a serious, life-threatening complication of CAPD. Most cases had PD duration of more than 4 years. Careful monitoring by CT scans of the peritoneal membrane in patients beyond 5 years, and early catheter removal in patients with peritoneal thickening should be considered for long-term CAPD patients. Treatment with tamoxifen may be of benefit in these patients.
 
Hoya11 said:
no its because they dont take epidurals on the floor, and when you send someone to the unit with an epidural its non-stop pages, like i said not the cream of the crop place, they freak out when there are thoracic epidurals after thoracotomy. overall frequency of epidurals in the hospital in general is about 1 every 2-3 months! im trying to change this culture, being a pain guy. Because there are plenty of surgeries that warrant them, but due to surgeon refusal (insane), pharmacy confusion (so you want bupivicaine in a bag? how should i mix it?) i pulled it. i would have loved to leave it in and run a dilute infusion but then there would have been freak out, and at 1/8% this lady would have still complained of pain and same events happen plus the pages about the epidural and then blaming the epidural for any complications as opposed to the morphine. SHe also had a fluctuating INR for unknown reasons with it being 2.3 one month. it was even raised during the code that the epidural (Which was removed 6 hrs prior to the event) was responsible, as opposed to the morphine, this is the kind of place im at, the next person below me on the totem pole is a PA covering the whole ICU who is about 25 and started within the year, nice guy, but not competent for complex stuff. so i pulled it to keep it simple. im not convinced an infusion in the ICU would have prevented the morphine bolus. And who orders the morphine bolus? the ortho PA of course. A big problem in general at my hospital is that low or mid level practitioners make very important decisions in complex patients. There was actually a death because someone got the bright idea to put multiple tunneled catheters in place for a burn patient, and the pharmacy mixed 0.5% bupivicaine at 14ml/hr into multiple sites and the patient died, this was within last two years, still gun shy about local anesthetic and catheters after that. NO Peripheral nerve catheters are done. SO its not like i exactly have everything at my control there are system issues i have to deal with, obviously resulting in a less than ideal anesthetic.

But anyway, back to my question, so I guess continuous belly full of fluid is a thing? THe main concern I have is that I did not take a strong enough stance on having her belly drained, and dont get me wrong i got around it using regional, but did I need to? I couldnt believe he told me I couldnt drain it...
Click to expand...
Planktonmd said:
6 MINUTES! man you are slow, this should not take more than 30 seconds!
Click to expand...


It was an ORIF btw. Thanks for all the useful feedback, blocks would have also been a way to go, but i would have done a pop-sci and saphenous supplement. I have to say though in my experience, those blocks lead patients require to more sedation (greater risk for aspiration in her) than epidural anesthesia which is literally NO sedation necessary. I find the ankle ring block just plain ****ty. The saphenous nerve can be tricky to identify accurately due to differential anatomy, no true test of successful block (no motor block), and if you think you get it 100% of the time you are fooling yourself.

The main issue, the PD, i believe SHOULD have been stopped and then resumed, and I will raise this at the next meeting.

The place I work has its uspides. While it is currently well behind the times in acute pain/regional, we see a lot of traumas, GSWs, and other very interesting cases that keep me on my toes and I feel so welcome there because they know quality amongst the mediocre. Also its my home community hospital. Its surrounded by affluent communites, and lots of competition that takes away any quality providers (though many doctors are quality and from the local ivy league place, but keep this particular hospital on the back burner becuase i bet there reimbursements are so terrible due to payer mix) . So its in a bad position, but serves a very important purpose to the community that it is in, which I find appealing and hope to improve upon.
 
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Hoya11 said:
It was an ORIF btw. Thanks for all the useful feedback, blocks would have also been a way to go, but i would have done a pop-sci and saphenous supplement. I have to say though in my experience, those blocks lead patients require to more sedation (greater risk for aspiration in her) than epidural anesthesia which is literally NO sedation necessary. I find the ankle ring block just plain ****ty. The saphenous nerve can be tricky to identify accurately due to differential anatomy, no true test of successful block (no motor block), and if you think you get it 100% of the time you are fooling yourself.

The main issue, the PD, i believe SHOULD have been stopped and then resumed, and I will raise this at the next meeting.

The place I work has its uspides. While it is currently well behind the times in acute pain/regional, we see a lot of traumas, GSWs, and other very interesting cases that keep me on my toes and I feel so welcome there because they know quality amongst the mediocre. Also its my home community hospital. Its surrounded by affluent communites, and lots of competition that takes away any quality providers (though many doctors are quality and from the local ivy league place, but keep this particular hospital on the back burner becuase i bet there reimbursements are so terrible due to payer mix) . So its in a bad position, but serves a very important purpose to the community that it is in, which I find appealing and hope to improve upon.
Click to expand...

patients tolerate pop/saph blocks surprisingly well with just local. (u/s, no nerve stim).

ankle blocks work great in patients who are already neuropathic 😉

if nerves are intact you are right ankle blocks suck and i just do pop/saph.

the OP's management sounds just fine to me as well.

i am confused though - did they really put hardware in the ankle above an active diabetic foot infection?
 
BLADEMDA said:
My results for blocking the saphenous nerve with u/s at the adductor canal is 100 percent using 20 mls of local anesthetic. This lines up with the following study: https://ccme.osu.edu/RSSeriesBrochure/25549 - A Comparison of Ultrasound-Guided and Landmark-.pdf
Click to expand...

ANd how do you assess this success rate?

No, thank god, im in rural NH just north of MA line

"One limitation of our study was the end point of loss of sensation instead of postoperative analgesia. While our measure of loss of sensation to pinprick is common after nerve blockade, a more accurate measure would be measures of postoperative analgesia after foot and angle surgery. Furthermore, our study did not include obese patients where such ultrasound techniques are theorized to assist in nerve blockade due to difficult landmarks. Additionally, our patient population in this study consisted of healthy physically fit subjects in whom subtle changes in muscle strength may not have been detected."

Assessment of pain on "VAS" scores and brief pinpricks at random locations are hardly accurate ways to tell if you have a successful block. SHow be a large study with less or even equal opiod consumption with saphenous block compared to femoral and I would be shocked. The saphenous nerve is all over the place, just because you put the needle where you read in the book doesnt mean you have a successful block. Patient pain reports are variable and anatomic location is variable. This is whey there is no evidence for most pain management procedures. If i NEED to cover the medial foot or lower extremity I do a femoral, say "raise your leg", and when they cant do that, that is a successfull block, successful sensory only blocks are hard to assess IMO
 
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80% or more of the time the Saphenous nerve is visible on U/S so the success rate is going to be very high. It's unfortunate your success rate isn't at least 95% with U/S for that nerve.
 
dhb said:
Really?? i feel like i'm guessing it's location >80% of the time
Click to expand...

I agree with Blade although I'd venture to say it's visible closer to 90% of the time. Try going a little higher on the leg. I put my probe down at the half-way point between the ASIS and the proximal border of the patella then scan a few cm up and down till I get the best picture. Nerve is nice and round at at 3ish o'clock on the artery nearly every time.
 
You did everything right in this case, given your hospital's severely limited mental and physical resources. Lady has an ankle fracture + toe gangrene so either pop/fem, pop/saph, or epidural would be the way to go. I agree with you that even if you left the epidural catheter in, the morphine order would've still been written for the patient by ortho PA. While I'm tired of reading "Avoid nephrotoxic agents such as NSAIDs and IV dye. Avoid hypoxia and hypotension intraop. Avoid morphine and Demerol" in nephrologists' notes, now I see why they put that in.

Hoya11 said:
There was actually a death because someone got the bright idea to put multiple tunneled catheters in place for a burn patient, and the pharmacy mixed 0.5% bupivicaine at 14ml/hr into multiple sites and the patient died, this was within last two years, still gun shy about local anesthetic and catheters after that (not my case of course).
Click to expand...

This is terrifying.

Hoya11 said:
But anyway, back to my question, so I guess continuous belly full of fluid is a thing? THe main concern I have is that I did not take a strong enough stance on having her belly drained, and dont get me wrong i got around it using regional, but did I need to? I couldnt believe he told me I couldnt drain it...What difference could it possibly make vs the potential anesthetic risks. And I think she vomitted in part becuase of her full extraperitoteanl space compressing her most recent meal, so I think the full belly made her significantly more risk for aspiration and if on MV im certain we'd see high PIPs limiting ventilation. And yes it was an ORIF, long and brutal.
Click to expand...

Which is more concerning to you, her missing out on a few hours of what seems like an already ineffective dialysis or her aspirating and ending up on prolonged mech vent? Your decision to drain the belly would trump the nephrologist's unsound clinical judgment (as long as you document meticulously, of course, with minimal finger pointing), but it also sounds like she has enough risk factors other than the PD fluid alone that would put her in full stomach category. Moreover, she threw up 6 hrs postop, when PD would've been resumed. In any case, no fault on you here.
 
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