Clinical case: intraop hypoxemia during robot partial nephrectomy

[urge]

And those of you who pointed out the location of the OG were correct. Official rads read for the first supine chest:



- Tip of the NG tube is above the GE junction with the proximal port at the level of T7. This could be advanced 15 cm to ensure that the proximal port is below the GE junction

Is the NG not being deep of significance to the clincal decompensation?

I think people concerned with the NG were implying that it had perforated the esophagus, ended somewhere in the lung, pleura, mediastinum, etc., because it was on the right side of the chest.

Or do we honestly think he desated and had a horrible x ray because the NG wasn't deep enough?

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[urge]

Even if you can't see it, in this clinical context, you should know that this is a plug. Unless this pt grew an obstructing tumor over the past 5 min you don't know about

It should have been picked up on the initial bronchoscopy, before the x ray, which was "normal tube position with minimal mucous secretions" or something like that.

 

[urge]

Remember the CXR is in the supine position so don't expect to see the typical effusion picture in the lower part of the hemithorax.
And as for putting a tube for a CO2 pneumo , if the patient is hypoxic and hypotensive you need to treat all the possible causes because you might not have enough time to be an internist or a philosophe here!

Hmmm. Guess the chest tube wasn't needed after all.

Pleural effusion disappeared also.

 

[Ezekiel2517]

It should have been picked up on the initial bronchoschopy, before the x ray, which was "normal tibe position with minimal mucous secretions" or soething like that.

they just used the scope to check tube position, they didnt go deeper.

 

[Noyac]

I'm confused! All of this for a mucus plug? Is that what I'm supposed to believe?

 

[Orin]

Mucus plug with gastric insufflation causing decreased lung volumes plus a red herring from the diaphragmatic tear. It's good to recognize and appreciate the cognitive biases here.

In this case, the concern for the PTX added a lot of extra risk/harm for what could've been a quick bronch/mucus plug/fix/proceed scenario.

 

[urge]

they just used the scope to check tube position, they didnt go deeper.

A missed opportunity.

 

[urge]

I'm confused! All of this for a mucus plug? Is that what I'm supposed to believe?

It was underwhelming. I agree.

It was still good. It uncovered some gross deficiencies of the collective. We royally suck at reading x rays. Suck using the bronchoscope. Suck of managing pneumothoraces. And probably some others that I cannot remember.

 

[Planktonmd]

I'm confused! All of this for a mucus plug? Is that what I'm supposed to believe?

An invisible mucous plug that they could not see on bronchoscopy and a pneumothorax that disappeared!

 

[Planktonmd]

Hmmm. Guess the chest tube wasn't needed after all.

Pleural effusion disappeared also.

The chest tube was not done but that does not mean it was not needed!!! Pneumo + Hypoxia + Hypotension ---> chest tube.
As for the effusion who told you it disappeared??? Now it is bilateral in the bases (on an erect CXR) and some fluid remains loculated in the fissure on the right.
And the radiologist admits discretely that she neglected to mention the effusion on the first CXR:
"Overall appearance of the study is improved with less fluid density in the right pulmonary apex since prior study. "

 

[vector2]

Even if you can't see it, in this clinical context, you should know that this is a plug. Unless this pt grew an obstructing tumor over the past 5 min you don't know about

So a couple things that make this scenario easy to Monday morning qb but not so easy in the room- for whatever reason rads sent us the one tech who had a portable machine that didn't have the damn screen on the machine. After the first hemithorax shot, my staff and I actually walked back with the tech to the dept so we could see the film and curbsided the resident to look at a possible ptx. After this cxr is when we bronched, and certainly it was our fault for not checking more segmental bronchi, but at the same time it wasn't exactly a super obvious thing to do when the trachea and r and l mains looked pretty clear. We had to call the same tech back to the room to shoot a proper AP, walk over again to eyeball the film, and then of course wait some more for a proper read- this entire time the pt was still not doing that great, therefore cancelled.

Secondly, the patients sat and abg did not improve in the next 10 seconds after the RUL was suctioned was in the ICU, but rather took a few hours. It's not clear that the case could've been continued safely with insufflation instead of doing it open even if properly bronched in the or. I mentioned the OG because obviously a big gastric bubble isn't helping our pulmonary mechanics.

 

[urge]

So a couple things that make this scenario easy to Monday morning qb but not so easy in the room-

I apologize if you feel that way. Criticism improves practice. Thanks for bringing up the case.

 

[skypilot]

I apologize if you feel that way. Criticism improves practice. Thanks for bringing up the case.

Gotta say. I really enjoyed that case! Even though it ended up being just a mucous plug I could feel the frustration and anxiety as the differential diagnoses were eliminated one by one.

 

[vector2]

I apologize if you feel that way. Criticism improves practice. Thanks for bringing up the case.

More of a response to Ezekiel whose initial glib reply was essentially 'duhhh of course it's a mucous plug why didnt you suction it and proceed you dummy.' That's why I provided the chronology and the equipment available to us so he could consider that we couldn't even look at the films as they were shot in the room. Scenarios IRL don't necessarily play out as neatly as a beautifully answered oral board stem.

If he wanted to improve practice with his criticism, it would've been nice of him to share some CXR reading knowledge cause I don't think it was clear to any of us at the time (including the SICU attending who eventually bronched and suctioned a small amount of secretions from the RUL) that a mucous plug was the definitive and only etiology of his respiratory distress.

 

[urge]

More of a response to Ezekiel whose initial glib reply was essentially 'duhhh of course it's a mucous plug why didnt you suction it and proceed you dummy.' That's why I provided the chronology and the equipment available to us so he could consider that we couldn't even look at the films as they were shot in the room. Scenarios IRL don't necessarily play out as neatly as a beautifully answered oral board stem.

If he wanted to improve practice with his criticism, it would've been nice of him to share some CXR reading knowledge cause I don't think it was clear to any of us at the time (including the SICU attending who eventually bronched and suctioned a small amount of secretions from the RUL) that a mucous plug was the definitive and only etiology of his respiratory distress.

It was clear once the outcome was known.

You know the saying: hindsight is 20/20.

 

[deleted171991]

I'm confused! All of this for a mucus plug? Is that what I'm supposed to believe?

It can happen. I see it monthly in the ICU.

 

[Ezekiel2517]

More of a response to Ezekiel whose initial glib reply was essentially 'duhhh of course it's a mucous plug why didnt you suction it and proceed you dummy.' That's why I provided the chronology and the equipment available to us so he could consider that we couldn't even look at the films as they were shot in the room. Scenarios IRL don't necessarily play out as neatly as a beautifully answered oral board stem.

If he wanted to improve practice with his criticism, it would've been nice of him to share some CXR reading knowledge cause I don't think it was clear to any of us at the time (including the SICU attending who eventually bronched and suctioned a small amount of secretions from the RUL) that a mucous plug was the definitive and only etiology of his respiratory distress.

wow, so sensitive lol. First, I never responded with a duh or call anyone dummy so just relax. I didn't even mention quite a few other things which I believe indicate possible lack of knowledge and/or experience in this case. I'm sorry but if you're a senior level reisdent, Im assuming you've done quite a few icu rotations. You should have learned by now how to properly read a portable chest film, since nearly every pt in the unit gets one every single day. This is pretty basic.
You stated that after you got a proper film, you guys went over and saw it. Do you agree that the lobar collapse is pretty obvious? Keeping that collapse of the lobe in mind, please tell me what else in this pt and this clinical context could possibly cause the acute hypoxia you described? I mean within reason, there is only one thing that could have caused this.
You also stated that the pt's sats did not improve over the next 10 sec after the bronch. I am guessing that is because the lungs were not reexpanded by bagging or hyperinflation. I mean that is a pretty basic maneuver to open up lungs with atelectasis.
So the pt is taken back to the unit and "optimized" and now the case is done open when the pt returns. IMO, this is a case that could have been done robotically as originally intended and it would have been much more beneficial for the pt to have done so.
Look, if you want to hear that you guys did everything perfect, fine just ignore all this. I am simply saying that I disagree and I think my criticisms are pretty reasonable.

 

[vector2]

wow, so sensitive lol. First, I never responded with a duh or call anyone dummy so just relax. I didn't even mention quite a few other things which I believe indicate possible lack of knowledge and/or experience in this case. I'm sorry but if you're a senior level reisdent, Im assuming you've done quite a few icu rotations. You should have learned by now how to properly read a portable chest film, since nearly every pt in the unit gets one every single day. This is pretty basic.
You stated that after you got a proper film, you guys went over and saw it. Do you agree that the lobar collapse is pretty obvious? Keeping that collapse of the lobe in mind, please tell me what else in this pt and this clinical context could possibly cause the acute hypoxia you described? I mean within reason, there is only one thing that could have caused this.

Those weren't your exact words but it was the implication I got from the tone- if that wasn't your intention then I guess my b. I've seen enough portables that mucous plug was the top ddx but as I said before, case was essentially already cancelled by the staff anesthesiologist and the surgeon in the room while another attending who was called for help and I walked over to rads again to see the second film. Additionally, if you were actually following this thread, there were multiple people after I posted the films who were spitballing things like worsening pneumo on the left, pleural effusion, ETT malposition, tracheal/bronchial anatomy variant, so let's not pretend that we're all CXR experts after doing a couple ICU rotations.

You also stated that the pt's sats did not improve over the next 10 sec after the bronch. I am guessing that is because the lungs were not reexpanded by bagging or hyperinflation. I mean that is a pretty basic maneuver to open up lungs with atelectasis.

Seriously? Tell me again that you're not calling us dummies.

So the pt is taken back to the unit and "optimized" and now the case is done open when the pt returns. IMO, this is a case that could have been done robotically as originally intended and it would have been much more beneficial for the pt to have done so.
Look, if you want to hear that you guys did everything perfect, fine just ignore all this. I am simply saying that I disagree and I think my criticisms are pretty reasonable.

I don't know in what universe you got the impression I thought everything was done perfect, whether it be the first poor lateral CXR, failure to bronch RUL, cancelling too soon etc, and no one here is disputing that a robotic resection would've been more beneficial. Some of these decisions such as whether to proceed again open were out of our control as the surgeon felt more comfortable that way. What I do know is that the patient still had pulmonary congestion, elevated peaks, relatively low Pa/Fi, a big ass belly, and a bitch of an airway even after the lung was expanded, so I think leaving him intubated was a defensible position considering his return to the OR was imminent.

 

[meister]

Interesting discussion to this radiology outsider. I will say that new lobar collapse in an ICU patient is mucus plugging until proven otherwise however considering this patient had a proven ?confounding PTX I can easily understand the clinical course.

 

[Planktonmd]

There was nothing clear or obvious about this case or the CXR in the beginning and the confusion was not surprising at all.

 

[Chloroform4Life]

I think the main lesson of this case is to be very skeptical of what you see on portable CXRs. Especially in the OR and ICU. These are not your standard looking PA and lateral.

These are hastily done with patients in all sorts of positions and often malrotated. You think you see a small effusion? No, there's actually 2L of fluid in that chest. Is that a large pneumothorax? No that's just some wierd looking shaddow. Is that pneumonia? No, the image was just taken at end expiration. Does this patient have ARDS? No, he's just fat. Etc etc