Here is my first case. I did this cases recently and it shows some of hazards of short, SDS cases.
53 year old Morbidly Obese White Male for Bronchoscopy under General. Pulmonary Physician doesn't like MAC for these case and he usually takes 20 minutes.
Here are a few Medical facts about the patient:
1. Morbidly Obese 130 Kg, 5'11''
2. STable Angina, Cardiac Cath in 2000 (negative) NO change in his symptoms
3. Post -Polio Syndrome getting worse each year. Now wheel chair bound with lower extremity weakness. No dysphagia per patient. Previous back operation 20 years ago
4. IDDM
5. HTN
6. GERD (asymptomatic with H2 blocker and proton pump inhibitor)
7. Gout
8. COPD (2ppd for 30 years, quit last week)
9. Recent CXR shows ? Left lower lobe infiltrate
10. Patient SNORES like heck at home and not sure about his breathing at night
11. Scheduled to go home today and wants BIGGY MEAL after the procedure
MEDS:
TOPROL XL
INSULIN
ALLOPURINOL
LISINOPRIL
ZANTAC
PREVACID
PROVENTIL/ALBUTEROL as needed
IMDUR
EKG; NSR
LAbs: Normal NO left shift, normal WBC, No fever
Well, what do you do? Remember, the guy is expecting to go home shortly after the case and wants a biggy meal via the drive thru.
I did the case and it went fine. I will post what I did and let you criticize (I would do the same thing again though) my approach tomorrow.
Blade
Polio stuff makes these patients sensitive to everything....and their recovery is longer....so doing this case in an SDS is a stretch...but hey, I'm game...
Less drugs is more in this guy.
Make sure he's beta blocked.
No opiods. No muscle relaxant....yeah, you can use depolarizer/non depolarizer but with the potential for prolonged effect I'd at least try to not use them.
He's asymptomatic on his GERD meds. GERD doesnt bother me unless they complain of postural GERD symptoms.
Monitors on, pre02, reverse T-berg.
Propofol 200mg.
Oral airway in when his gag is gone.
Crank the sevo to max, keep your 02 flow at 10 liters/min, and give him small, non-gastric-insufflating tidal volumes for a cuppla minutes. Use two people if you have to...one dude holding the mask, the other squeezing the bag.
When you are satisfied that he's got some gas on board insert da snorkel. He shouldnt fight if you've got enough gas on board because the gas + propofol should be enough. If he fights, now you dont have a choice. The 20mg roc that Noy and Venty mentioned sounds like a good dose. But again, your life will be easier if you can avoid it.
Reduce sevo to 5%, turn the bed, attach bronch-side-port-thinghy.
Keep him still with gas. Reduce sevo to 3% after five minutes or so if able.
If he gets hyperdynamic, use a beta blocker of your choice.
Suck his stomach out with OGT at end before extubating like Venty said.
If you had to use rocuronium, give full reversal.
Extubate, to PACU.
Have a Mexican Pizza, two bean buritos, three Taco Supremes, and large mountain dew waiting.
Have him read the-funnies on the side of the Fire Sauce packets to pass the time.
Between bites, he's probably gonna need to suck on a nebulizer with all the instrumentation done to a very hyper-reactive broncho-pulmonary tree.