C6 quadriplegic scheduled for cysto and fulguration

[Low Flow]

Injury was 30 years ago. No records in our system of a previous GA (just MAC and peripheral regional). Is your practice to attempt spinal anesthesia or just go with LMA and GA with nicardipine handy if they do have autonomic dysreflexia? This particular patient has a baclofen pump around L1.

---

Members don't see this ad.

 

[Mman]

a nice general anesthetic tends to prevent autonomic hyperreflexia

 

[IMGASMD]

GA.

 

[AnesRunner]

Why would you even consider a spinal on this patient? That's the main question.

 

[GassYous]

General

 

[GassYous]

Why would you even consider a spinal on this patient? That's the main question.

Difficult airway?

 

[AnesRunner]

There are no circumstances in which I would do a spinal on someone with a prior C-spine injury/quadriplegia and an IT pump/catheter. Awake intubation if worried about a difficult airway or intubating LMA/asleep FOI.

 

[amyl]

Deep ga. Lma or tube, either is fine. Deep. If he/she acts up…. Deeper

 

[chocomorsel]

GA.

Why would you even consider a spinal on this patient? That's the main question.

HAHA. Because even though they have a spinal cord transection, somehow, someway, we have Voodoo drugs that can work below the injury. You know, that's what we do behind the drapes. Voodoo. Soduku. Stock Market.

 

[woopedazz]

I spinal these. The incidence of AD is higher than we expect in cystocopy surgery. We do a "spinal for tetraplegics" cystoscopy list per month and prior to that being initiated the anaesthetists who did that list said they had a number of bad events.

 

[Hoya11]

Injury was 30 years ago. No records in our system of a previous GA (just MAC and peripheral regional). Is your practice to attempt spinal anesthesia or just go with LMA and GA with nicardipine handy if they do have autonomic dysreflexia? This particular patient has a baclofen pump around L1.

LMA is very easy.

Would not spinal - unneccessary especially in this case - its already done for you!

I have done these cases with no anesthesia and stood by to give beta blocker or versed PRN depending on the patients sensation.

 

[DrOwnage]

Would not spinal - unneccessary especially in this case - its already done for you!

That's not how the pathology works though.

 

[coffeebythelake]

Would not spinal - unneccessary especially in this case - its already done for you!

I have done these cases with no anesthesia and stood by to give beta blocker or versed PRN depending on the patients sensation.

Spinal would block sympathetics and will reduce intensity or completely prevent of autonomic dysreflexia.

Can you please elaborate on your no anesthetic plan? Fast acting BB maybe, or nitroglycerin, or nocardipine, etc.. but How would giving versed prn make a difference?

 

[Low Flow]

Case ended up getting moved to another room, but I glanced at the chart to see how it went. The team elected for general with an LMA. Pre treated with 80 mcg of atropine. No opiates before incision. Right after the incision mark in the record (which I assumed was insertion of cystoscope), pulse went to 33 and first cuff pressure was 265/143. Gave some more atropine, prop, increased sevo, and fentanyl and came back to normotension after 10 minutes. ET sevo concentration didn't look that high for his age prior to incision so maybe he was pretty light. Kinda bummed I didn't get to do this case honestly.

 

[Hoya11]

Spinal would block sympathetics and will reduce intensity or completely prevent of autonomic dysreflexia.

Can you please elaborate on your no anesthetic plan? Fast acting BB maybe, or nitroglycerin, or nocardipine, etc.. but How would giving versed prn make a difference?

Yes but so would GA.

Im not sure what a spinal buys here other than messing around with an already messed up spine.

Have you never encountered these patients who have done these procedures over and over with no anesthesia?

I have had many patients tell me they have no feeling, have done this procedure before, and dont want anesthesia.

So we explain autonomic HR and stand by. VERY often we are not needed and there is no autonomic hypereflexia and no feeling at all. And so we just give a little versed or nothing.

Why does a spinal chord injury buy you a spinal when plan A is LMA for everyone anyways? Why does the idea of the messed up spine make you want to attempt a spinal?

 

[IMGASMD]

Case ended up getting moved to another room, but I glanced at the chart to see how it went. The team elected for general with an LMA. Pre treated with 80 mcg of atropine. No opiates before incision. Right after the incision mark in the record (which I assumed was insertion of cystoscope), pulse went to 33 and first cuff pressure was 265/143. Gave some more atropine, prop, increased sevo, and fentanyl and came back to normotension after 10 minutes. ET sevo concentration didn't look that high for his age prior to incision so maybe he was pretty light. Kinda bummed I didn't get to do this case honestly.

It happens soooo fast. I did one in training, maybe as CA2? My attending must have been in another room to start.

I thought I had the patient deep enough. MAC ~ 1.5. Maybe some fent before. Glyco.
Literally in the blink of an eye. BP shut up, HR in the 20s. Almost shat my pants.

I’ve learned another “trick” since. Nitro paste. That stuff is almost magic. I would even put it on before starting…. Wipe it off, and it’s gone.

 

[Hoya11]

That's not how the pathology works though.

not all patients read the book.

i have had many with absolutely no feeling and can have surgery below a certain level with no sensation or autonomic fiber activity.

definitely not plan A but it is out there and a reality

 

[GassYous]

It happens soooo fast. I did one in training, maybe as CA2? My attending must have been in another room to start.

I thought I had the patient deep enough. MAC ~ 1.5. Maybe some fent before. Glyco.
Literally in the blink of an eye. BP shut up, HR in the 20s. Almost shat my pants.

I’ve learned another “trick” since. Nitro paste. That stuff is almost magic. I would even put it on before starting…. Wipe it off, and it’s gone.

a line?

 

[UscGhost]

Case ended up getting moved to another room, but I glanced at the chart to see how it went. The team elected for general with an LMA. Pre treated with 80 mcg of atropine. No opiates before incision. Right after the incision mark in the record (which I assumed was insertion of cystoscope), pulse went to 33 and first cuff pressure was 265/143. Gave some more atropine, prop, increased sevo, and fentanyl and came back to normotension after 10 minutes. ET sevo concentration didn't look that high for his age prior to incision so maybe he was pretty light. Kinda bummed I didn't get to do this case honestly.

Curious...what's the rationale for pretreatment with atropine?

Isn't the issue primarily SNS overload leading to HTN and reflexive bradycardia? Not sure bradycardia is the issue that warrants pretreatment versus opiods plus high mac or pretreat with labetalol. Would an elevated HR along with severely elevated PVR lead to an even higher BP?

I haven't treated a patient like this since residency so just curious

 

[chocomorsel]

I spinal these. The incidence of AD is higher than we expect in cystocopy surgery. We do a "spinal for tetraplegics" cystoscopy list per month and prior to that being initiated the anaesthetists who did that list said they had a number of bad events.

Please explain how this is better than a general. I am all about the Spinal is already done for me.

 

[IMGASMD]

a line?

Nope.
It was the sudden drop of heart rate…. Panic….
Cycle the cuff….
Shat my pants…
Tried to get my attending…
Lots and lots of prop…..

I think the patient had been done before, we probably decided it was fine, just keep him deep.

I don’t exactly remember the sequence of events; all I remembered was by the time my attending finally got back. The vitals were better…… at least the HR was much more compatible with the “normal” value.

 

[JiPo]

Would you do an A-line in these patients routinely if there was no prior anesthesia record?

 

[deleted875186]

What is the issue with a spinal, it is a cervical cord injury, no issues with the lumbar spine. Of course you need to view the records to see where the baclofen catheter is and go well below it. For this that think there is an infection risk, remember these patients get a refill through the skin every 3 months anyway, hardly ever get infected. I agree it’s more work, but a spinal would be fine. Main issue is do not hit the ITP catheter, you need to know what level is accessed, I doubt it’s L1 as most peoples condos is L1 or L2, maybe that’s where the catheter tip is sitting, although typically they are threaded much higher.

 

[BobLoblaw78]

Spinal or Deep GA. Spinal is better about blocking the reflex. So spinal is the better answer. But I will do deep general as many times they already have a trach and will be on a vent... but I still see elevated BP's. Reflex still happens even with transected cord. Spinal cord still works to a degree below the transection.

My biggest concern with spinal in this case would be causing issues with the intrathecal catheter.

 

[DrOwnage]

I would have GETA'd this patient. In certain circumstances where you need to get the patient deep or control hemodynamics very precisely an LMA isn't worth the convenience of a smoother wake up. With the tube you can control ventilation, ensure accurate ET concentrations of sevo without leaks, and give high doses of opioid without having to worry about the patient not breathing on the LMA. LMAs are great for run of the mill cases but when the patients get more complicated or I have concerns, I usually tube.

 

[pgg]

Case ended up getting moved to another room, but I glanced at the chart to see how it went. The team elected for general with an LMA. Pre treated with 80 mcg of atropine. No opiates before incision. Right after the incision mark in the record (which I assumed was insertion of cystoscope), pulse went to 33 and first cuff pressure was 265/143. Gave some more atropine, prop, increased sevo, and fentanyl and came back to normotension after 10 minutes. ET sevo concentration didn't look that high for his age prior to incision so maybe he was pretty light. Kinda bummed I didn't get to do this case honestly.

Oh for **** sake

Shakes your faith in humanity, doesn't it?

 

[nimbus]

I would have GETA'd this patient. In certain circumstances where you need to get the patient deep or control hemodynamics very precisely an LMA isn't worth the convenience of a smoother wake up. With the tube you can control ventilation, ensure accurate ET concentrations of sevo without leaks, and give high doses of opioid without having to worry about the patient not breathing on the LMA. LMAs are great for run of the mill cases but when the patients get more complicated or I have concerns, I usually tube.

Yep. When they’re tubed and paralyzed, you can do anything you like with the anesthetic.

 

[woopedazz]

Please explain how this is better than a general. I am all about the Spinal is already done for me.

You've still got sympathetic fibres coming out of an intact and upregulated spinal cord below the lesson. You're missing the patients ability to downregulate these twitchy reflex-stimulated pathways with their now severed inhibitory pathways. Hence the disaster sympathetic activity below the lesion, coupled with the disaster parasympathetic response above the lesion. A spinal acts at the site of the problem.

 

[anbuitachi]

Case ended up getting moved to another room, but I glanced at the chart to see how it went. The team elected for general with an LMA. Pre treated with 80 mcg of atropine. No opiates before incision. Right after the incision mark in the record (which I assumed was insertion of cystoscope), pulse went to 33 and first cuff pressure was 265/143. Gave some more atropine, prop, increased sevo, and fentanyl and came back to normotension after 10 minutes. ET sevo concentration didn't look that high for his age prior to incision so maybe he was pretty light. Kinda bummed I didn't get to do this case honestly.

thats probably the problem. would definite achieve high mac before starting, either with sevo, or combine it with IV meds like propofol and fent on board

 

[woopedazz]

Case ended up getting moved to another room, but I glanced at the chart to see how it went. The team elected for general with an LMA. Pre treated with 80 mcg of atropine. No opiates before incision. Right after the incision mark in the record (which I assumed was insertion of cystoscope), pulse went to 33 and first cuff pressure was 265/143. Gave some more atropine, prop, increased sevo, and fentanyl and came back to normotension after 10 minutes. ET sevo concentration didn't look that high for his age prior to incision so maybe he was pretty light. Kinda bummed I didn't get to do this case honestly.

The choice to pre-treat with atropine is brain-dead. Borderline malpractice territory.

Atropine doesn't prevent AD; even if that had been their thought process, they would've been wrong. So they deliberately administered atropine for what reason? To oppose reflex bradycardia? To what end? To make sure he definitely explodes?

Then there's the dose selection of said atropine... 80mcg... It's like someone in the room knew it was the worst idea ever and just gave up. 80mcg......... What even is that?

 

[pgg]

Botching a case in this way is on the same level as slamming a spinal into a patient with critical aortic stenosis. Just WTF are they doing?

I mean, there are a bare handful of classic anesthesia clean kills, and autonomic hyperreflexia is one of them. If this was an oral board question it'd be a straight up kthxbye, see you next year.

 

[Mehd School]

I've done a lot of these as we have a plastic surgeon who's niche is debridement of complicated ulcers in this patient population. Also a handful of urology, but we try to do both procedures under the same anesthetic if possible.

People that are laughing at spinals haven't done enough of them. We do spinals whenever possible. I've done one where the patient was at 2 mac of gas, 350mcg of fentanyl and when the scope went in the HR went to 9. You can guess what happened next. Spinals are much, MUCH more consistent in blocking this exaggerated sympathetic response. Unfortunately in this population it isn't uncommon that a spinal is near impossible to do.

 

[GassYous]

I've done a lot of these as we have a plastic surgeon who's niche is debridement of complicated ulcers in this patient population. Also a handful of urology, but we try to do both procedures under the same anesthetic if possible.

People that are laughing at spinals haven't done enough of them. We do spinals whenever possible. I've done one where the patient was at 2 mac of gas, 350mcg of fentanyl and when the scope went in the HR went to 9. You can guess what happened next. Spinals are much, MUCH more consistent in blocking this exaggerated sympathetic response. Unfortunately in this population it isn't uncommon that a spinal is near impossible to do.

It isn't that spinals are bad, just this patient has something intrathecal and no one wants to get blamed if something happens to it

 

[Mehd School]

It isn't that spinals are bad, just this patient has something intrathecal and no one wants to get blamed if something happens to it

Maybe half or more of the patients I've taken care of have intrathecal pumps. Almost always at L1 and sometimes higher. I'm not getting into the subarachnoid space at L1. The catheters typically take a cephalad course.

 

[UscGhost]

It isn't that spinals are bad, just this patient has something intrathecal and no one wants to get blamed if something happens to it

People just use that as an excuse because they don't want to do the spinal.

No chance you will hit a stim lead or catheter with your needle so the risk is negligible. And those leads and pumps arent keeping patients alive..so what if it did get damaged. Patient just needs it replaced, they can't sue you for that.

Combined with the fact that it is well established that a spinal is safer due to the risk of hemodynamic instability unique to this population...you are fine.

Just document appropriate consent and move on.

 

[deleted875186]

It isn't that spinals are bad, just this patient has something intrathecal and no one wants to get blamed if something happens to it

Catheter tip is radio opaque, also there is an incision in the lumbar spine where the implanted cut down to get down to the spine, just go below this, the catheter is placed intrathecal at the level of the lumbar incision and then tunneled around anterior lumbar, it’s anchored in fascia at the lumbar incision, if you go below you’ll be fine.

Again, infectious risk is no higher than when they great their q3month refill with t pain clinic or neurosurgery clinic.