Your Most Challenging Case?

[Pietrantonio]

During your years in residency and after, what has been your most challenging case(s)?

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[Multifidus]

Patients with severe pulmonary hypertension have presented the most challenge for me.

 

[G0S2]

Patients with severe pulmonary hypertension have presented the most challenge for me.

I was going to say. Double lung transplants for me. There is always that time in the case where patient tries very hard to die.

 

[Mman]

I was going to say. Double lung transplants for me. There is always that time in the case where patient tries very hard to die.

I'm very glad to not have to do those. As a resident, they were my most challenging cases (especially since they are off pump). One lung ventilation on somebody who is barely alive with 2 lungs and massive hemodynamic swings are not easy to manage.

 

[Pietrantonio]

Patients with severe pulmonary hypertension have presented the most challenge for me.

So what are you interventions during the procedure? Nitric Oxide, et al?

I had to ask this thread question because years ago I elected to have an inguinal hernia repair and shortly after the induction of anesthesia I went into severe HTN. A later diagnosis would conclude an extra-adrenal pheochromocytoma. It just sparked my interest to learn of the more complicated cases out there.

Thanks for the replies so far.

 

[epidural man]

During your years in residency and after, what has been your most challenging case(s)?

MAC cases in young marines with severe PTSD -

MACs in general can be very challanging. I know that sounds strange....

I don't do transplant anesthesia - The few livers I did were crazy. I can see why those are very challanging.

 

[IlDestriero]

Teenager with VSD, maybe ASD as well, don't remember all the details.
Severe pulmonary hypertension, awaiting heart and lung transplant, but not sick enough yet.
Eisenmenger physiology. Pulmonary pressures equal systemic at start of case with nitric, etc.
Severe scoliosis causing pulmonary complications.

Needs posterior spinal fusion to stabilize the worsening scoliosis, so the patient can survive long enough to get the heart/lung tx.

1st half of case- no problem. Actually doing much better than expected. Than ...
Uh oh ...
Over 2 min pulmonary pressures go to about 2x systemic.
Much drama ensues.
Pt survived, neuro intact, and left the PICU after a couple weeks.
High fives all around.
($5 says independent CRNA would have offed the pt on induction.)
Liver transplants can be pretty dramatic from time to time. I don't miss them.

 

[proman]

My toughest so far: the liver transplant who was anhepatic for 3 days.

Lung transplants suck. Hearts can suck but there's always a VAD. We all worry about AS or pulmonary hypertension, the case that squeezes my adrenals is mitral stenosis. Those patients drop dead quick.

 

[ssmallz]

Healthy kids may not be tough cases but they are the ones that scare me the most. Sick pts are sick, everyone knows they are sick, and everyone including the family understands that there are risks and this patient very well might die. We get a ton of access in them, use all the monitors we can think of, and are hypervigilant. If nothing happens then you're a rock star, if it goes south then the pt was really sick and you did your best. Kids start off healthy and they tank FAST!! Lucky for us that they come back quick and they do fine most of the time, but try explaining to mom why her healthy 3 y/o who came in for a routine T&A and is now a vegitable. Way worse than offing the 50 year old w/stage 4 pHTN or ESLD for a liver tx.

 

[dhb]

Left pneumonectomy with resection of the descending aorta and part of the left artium with low aortic canulation and pulmonary artery canulation.
Radial and femoral alines with a finger on the norepi to try and balance top and bottom pressures.
I was happy when we went on bypass as it was the perfusionist that had to deal with the pressures by constantly modifying the clamp on the "venous return" from the PA.