We postpone an AKA case, but why? How would you deal with it?

[deleted697535]

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No way I am doing regional only for an AKA!

Yeah any regionalists care to chime in here? Ive done it for bka with sedation but never aka.
Definitely not for a guy who cant lie flat

30% EF with severe MR? That’s more like 15% forward flow. You’d do prop sux tube without an art line in that patient?

Yeah thats Russian roulette really.

 

[Volatile]

I would do popliteal and adductor blocks and then go to sleep

this won’t be helpful for this case. I have done exactly one AKA under regional with high femoral/sciatic blocks but I wouldn’t want to do it routinely, I would always be concerned about my coverage. I will say I have done post-op rescue femoral/sciatic blocks for AKA’s and they have gotten quite comfortable so maybe the coverage is better than I give credit for 🤷🏼‍♂️

 

[FiO2@21]

this won’t be helpful for this case. I have done exactly one AKA under regional with high femoral/sciatic blocks but I wouldn’t want to do it routinely, I would always be concerned about my coverage. I will say I have done post-op rescue femoral/sciatic blocks for AKA’s and they have gotten quite comfortable so maybe the coverage is better than I give credit for

Initially thought it was a BKA.

I would still do a fem/sciatic before/after going to sleep depending on anatomy/risk tolerance. Anything to even slightly reduce post op opioid use.

 

[FiO2@21]

When I was a resident, I worked with an anesthesiologist who had trained and practiced in rural India. He showed me how to transduce an arterial line using a sphygmomanometer (no electricity necessary, just watching the needle jump mechanically on the dial). I wish I could recall the details of how he set it up… All I remember is that there was an air-fluid interface in the tubing that moved towards the patient, you had to keep an eye on it and reset periodically lest you give the patient an air embolus

anyone here ever seen or done anything like that? If we could figure it out, might prove useful for Dr Amir

The height of blood in manometry tubing that’s used with central lines gives you the MAP when you hit the carotid, right?

Maybe they could cannulate the radial and suspend some tubing against a ruler? All you need is the MAP anyway

 

[MirrorTodd]

Man Dr Amir, all I gotta say is I have mad respect for you over there. The situations you are faced with are not easy and highlight just how well we have it over here in the states where our major concerns are more along the lines of ornery circulators and anesthesia techs with bad attitudes.

 

[dhb]

Yeah any regionalists care to chime in here? Ive done it for bka with sedation but never aka.
Definitely not for a guy who cant lie flat

Yeah thats Russian roulette really.

High sciatic and femoral get's the job done. I've done plenty of these trust me. I almost never sedate them, they usually fall asleep once the block kicks in and the limb that's been keeping them awake for days is insensate.
Sometimes they complain in the obturator's dermatome but it's not a big issue: at least they're alive.

 

[DrAmir0078]

High sciatic and femoral get's the job done. I've done plenty of these trust me. I almost never sedate them, they usually fall asleep once the block kicks in and the limb that's been keeping them awake for days is insensate.
Sometimes they complain in the obturator's dermatome but it's not a big issue: at least they're alive.

How about obturators?

As we know AKA needs 5 nerves to be blocked : LCN, FN, AON, PON, and SN !

 

[vector2]

RA solo does not sound like a viable option. Mostly because it seems ill advised to do an AKA sans tourniquet given the very elevated venous pressure, elevated INR, possible congestive hepatopathy, possible platelet dysfunction from uremia/CKD, and high likelihood that he was on A/C, antiplatelets, or both in the preceding days before surgery.

 

[FiO2@21]

RA solo does not sound like a viable option. Mostly because it seems ill advised to do an AKA sans tourniquet given the very elevated venous pressure, elevated INR, possible congestive hepatopathy, possible platelet dysfunction from uremia/CKD, and high likelihood that he was on A/C, antiplatelets, or both in the preceding days before surgery.

I feel like I heard from a surgery resident that tourniquets aren’t recommended anymore.. but maybe that’s for BKA

 

[vector2]

I feel like I heard from a surgery resident that tourniquets aren’t recommended anymore.. but maybe that’s for BKA

Above the Knee Amputation : Wheeless' Textbook of Orthopaedics

(see also: AKA Prosthesis, Amputations in the Diabetic Patient Discussion average AK amputee walks 43% slower and expends 89% more kcal/min than the normal person; if proximal circulation is adequate, a longer anterior muscle flap may be left and the combination myodesis- myoplasty technique is...

www.wheelessonline.com

Wheeless is essentially the Miller of ortho. But I have seen AKA's done without one.

 

[GassYous]

View attachment 343956

Above the Knee Amputation : Wheeless' Textbook of Orthopaedics

(see also: AKA Prosthesis, Amputations in the Diabetic Patient Discussion average AK amputee walks 43% slower and expends 89% more kcal/min than the normal person; if proximal circulation is adequate, a longer anterior muscle flap may be left and the combination myodesis- myoplasty technique is...

www.wheelessonline.com

Wheeless is essentially the Miller of ortho. But I have seen AKA's done without one.

I thought orthobullets was the miller of ortho

 

[repititionition]

Wow... Pretty straightforward and healthier than 80 % of what you have seen... Seriously amazing!

So, wondering why even in India, Iran and private hospitals in Iraq with better facilities they did not risk giving him GA nor Regional / neuraxial ... At least out of Iraq, they love to profit from the patient, at least he could get his hip fixed !

There is problem in understanding the physiology at least!

I wish in a dream that one day I can visit one of the busiest hospital in the US, and grant one month observership to see such critically ill patients you guys manage easily, this will add up experience.

Impressive!

I’d be happy to help you with arrangements at my hospital.

 

[DrAmir0078]

I’d be happy to help you with arrangements at my hospital.

Thanks mate,
Once I graduate from the residency - I truly need a visit to USA my second Home, I am an American citizen too and file my tax every year - no issues with me. It has been exactly since October 2016 never been in the US and need such visit to close friends in DC and NJ. So will wait another year and a half. By then will plan to connect for observerships in busy hospital. It will be such great opportunity and experience.