Garbage clearances

[PpfSuxTube]

I’m not a cardiac anesthesiologist and no way in hell can I monitor those pressures in real time in this cripple

Yea they wanted to do the case
The mid level didn’t even bother with a Pulm consult either
I work at a podunk community hospital very bare bones and this is def not the patient that can be cared for properly here
The cards consult they got “cleared” him and of course it mentioned being high risk
Nothing that I didn’t know already

Gave a tiny amount of fentanyl 50mcg to help with a arterial line placement, guy crumped

De sat to 60s had to remove the nasal canulla and places on face mask tight seal cranked up O2 after about 3-4 mins with him de satting and his HR climbing to 140 he came
Back up to high 80s for pulse ox

I sent him to the pacu and they tried to keep his sats acceptable with nasal canulla but they had to switch him to a non rebreather.
I had him transferred him to a tertiary care center and followed him via epic (we don’t use it but basically every one else in the area does)

Low and behold proper cards and Pulm consult guy gets the things you mentioned and they do the case these with peng block (which I knew about but have never done and did not to try my chances on this crippple pt and have it not work)

My question is how do you know when to diurees these pts yes you can look at jvd, fluids status, leg edema listen to lungs etc
Asking in case I get some future surgeon who won’t transfer out even tho the patient is a terrible candidate

My gut instinct was to transfer from the beginning but the first cards consult ( hospital worked at) estimated his new pulm pressures to be moderate (50s) so I was thinking LMA pre induction art line, good IVs but after the episode above I didn’t proceed
He took is blood thinner so I couldn’t do neuraxial

I also wondered how did this old guy who refused pulm rehab for months and doesn’t even know what inhalers he uses or when have improvement in Pulm art pressues

Are they that liable just like our regualr
BP? Can be 180 one moment then 140 the next and then 100 the next

Is 50 of fent a tiny amount?
I think that's a decent dose, for a cardiac cripple it's a big dose...

Next time either tube with levo/mil running or do it wide awake... don't give fent to put the equivalent of a 20g IV in. Just put loads of local in for a lines...

I wouldn't do this with a peng block... why even bother with peng? Why not at least a real block like a femoral.nerve block? Worried about him not being able to do his physio post op? Or falling? Sounds like this guy ain't getting out of bed much

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[pgg]

Exactly why I prefer an endotracheal tube and controlled ventilation in these patients….to prevent the “death spiral”.



View attachment 380655



I think this has been posted before but it’s highly recommended

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001136

I am often surprised by how many people, including anesthesiologists, will argue that a general anesthetic with an LMA is somehow gentler or safer than a general with an ETT in these patients.

I almost never put LMAs in them. Why would I want the patient spontaneously (hypo)ventilating? It's a rare patient where I'm worried about adverse effects from PPV.

Paralyze, tube, be stingy with the opioids (or withhold them altogether depending on the surgery), extubate awake. Next.

LMAs are for healthy people.

 

[pgg]

Gave a tiny amount of fentanyl 50mcg to help with a arterial line placement, guy crumped

De sat to 60s had to remove the nasal canulla and places on face mask tight seal cranked up O2 after about 3-4 mins with him de satting and his HR climbing to 140 he came
Back up to high 80s for pulse ox

Don't give people fentanyl for art lines.

(Patients don't need midazolam, either.)

2% lido with a 27g needle above and beside the artery. Use ultrasound.

Avoid all of the above drama.

 

[GassYous]

I am often surprised by how many people, including anesthesiologists, will argue that a general anesthetic with an LMA is somehow gentler or safer than a general with an ETT in these patients.

I almost never put LMAs in them. Why would I want the patient spontaneously (hypo)ventilating? It's a rare patient where I'm worried about adverse effects from PPV.

Paralyze, tube, be stingy with the opioids (or withhold them altogether depending on the surgery), extubate awake. Next.

LMAs are for healthy people.

As I get on with my career I'm finding this to be the case.

 

[vector2]

Exactly why I prefer an endotracheal tube and controlled ventilation in these patients….to prevent the “death spiral”.



View attachment 380655



I think this has been posted before but it’s highly recommended

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001136

Apropos of the discussion

 

[nimbus]

Apropos of the discussion

Good timing on that tweet/X

 

[PpfSuxTube]

LMAs are for healthy pepeople.

Lmas are garbage.
The 9 that work wrll dont make up for the 1 that fails miserably and leads to an awful case

 

[pgg]

Lmas are garbage.
The 9 that work wrll dont make up for the 1 that fails miserably and leads to an awful case

Well, LMAs can keep simple anesthetics simple. There's something to be said for keeping some patients spontaneously breathing from the start without a need for paralysis (and reversal).

And it's not a decision you have to live with if it fails or annoys you. Worst case there is you take it out and put a tube in.

 

[Hoya11]

I am often surprised by how many people, including anesthesiologists, will argue that a general anesthetic with an LMA is somehow gentler or safer than a general with an ETT in these patients.

I almost never put LMAs in them. Why would I want the patient spontaneously (hypo)ventilating? It's a rare patient where I'm worried about adverse effects from PPV.

Paralyze, tube, be stingy with the opioids (or withhold them altogether depending on the surgery), extubate awake. Next.

LMAs are for healthy people.

disagree about lmas, they can simplify a complex situation, love to do old frail cardiac cripple hip fx under LMA and spontaneous breathing, not hypoventilating.. smoothness goes a long way

 

[neutro]

Lmas are garbage.
The 9 that work wrll dont make up for the 1 that fails miserably and leads to an awful case

Don’t agree with this logic

 

[vector2]

disagree about lmas, they can simplify a complex situation, love to do old frail cardiac cripple hip fx under LMA and spontaneous breathing, not hypoventilating.. smoothness goes a long way

I think it depends. Downside number 1, 2, and 3 for LMAs in cardiac cripples is that on average one needs more induction agent (as compared to a geta induction with paralytic) to achieve a degree of pharyngeal relaxation to allow for optimal LMA seating. Now I guess one could make the argument that one could simply use a small induction dose and a bit of sux to seat the LMA, but that begs the question of why not just do geta in the first place.

But even after that, downsides 4, 5, and 6 are the need to achieve an adequate ET vapor concentration to prevent the non-paralyzed pt from moving with surgical stimulation. For the average outpt knee scope with LMA for instance I have the sevo quite overpressurized before incision. Not quite so easy to do in the LVEF 20% pt with severe MR/pHTN. OTOH, if I have a tube in, I can just run a whiff of vapor right around MAC -aware, make sure a touch of ketamine and versed are on board, and let the roc do the heavy lifting.

 

[Arch Guillotti]

I think it depends. Downside number 1, 2, and 3 for LMAs in cardiac cripples is that on average one needs more induction agent (as compared to a geta induction with paralytic) to achieve a degree of pharyngeal relaxation to allow for optimal LMA seating. Now I guess one could make the argument that one could simply use a small induction dose and a bit of sux to seat the LMA, but that begs the question of why not just do geta in the first place.

But even after that, downsides 4, 5, and 6 are the need to achieve an adequate ET vapor concentration to prevent the non-paralyzed pt from moving with surgical stimulation. For the average outpt knee scope with LMA for instance I have the sevo quite overpressurized before incision. Not quite so easy to do in the LVEF 20% pt with severe MR/pHTN. OTOH, if I have a tube in, I can just run a whiff of vapor right around MAC -aware, make sure a touch of ketamine and versed are on board, and let the roc do the heavy lifting.

I let the surgical stimulation do the heavy lifting.

 

[pgg]

I let the surgical stimulation do the heavy lifting.

There are of course lots of correct ways to do things. But in general I don't like this practice for a few reasons.

A minor annoyance of mine is supervising CRNAs who let hypotension ride during prep, waiting for surgical stimulation to make them normotensive again. They do it with young people which is probably harmless (but lazy - give some phenylephrine or ephedrine ya bum) and they do it with old people (which is stupid and dangerous). Not suggesting you do either of these things.

The degree of surgical stimulation is quite variable, sometimes difficult to predict, and largely outside my control. There's too much hopium involved in that strategy for my taste.

In sick patients, the unblunted catecholamine surge of a scalpel isn't really desirable ... and if you've taken steps to blunt it, then it's not really helpful.


IMO hemodynamics should be managed with vasoactive drugs and anesthetic depth. Paralysis permits substantial reductions in anesthetic depth without compromising operating conditions.

 

[Hoya11]

I think it depends. Downside number 1, 2, and 3 for LMAs in cardiac cripples is that on average one needs more induction agent (as compared to a geta induction with paralytic) to achieve a degree of pharyngeal relaxation to allow for optimal LMA seating. Now I guess one could make the argument that one could simply use a small induction dose and a bit of sux to seat the LMA, but that begs the question of why not just do geta in the first place.

But even after that, downsides 4, 5, and 6 are the need to achieve an adequate ET vapor concentration to prevent the non-paralyzed pt from moving with surgical stimulation. For the average outpt knee scope with LMA for instance I have the sevo quite overpressurized before incision. Not quite so easy to do in the LVEF 20% pt with severe MR/pHTN. OTOH, if I have a tube in, I can just run a whiff of vapor right around MAC -aware, make sure a touch of ketamine and versed are on board, and let the roc do the heavy lifting.

I disagree with #1. I feel I can slip in an LMA with next to nothing compared to doing DL/Paralysis and feel ETT requires a heavier induction. And then once the LMA goes in they SV themselves nice and smooth breath to breath to a happy place. Very HD Smooth if you dont see a (mostly) inhalational induction in an adult. The gentlest induction there is..

#2 is a rarer bird than you are advertising. Usually someone who is old and sick is not going to fight at low vapor concentrations and a little narcotic. Yes every once in a while sure you can have someone who cant tolerate the anesthetic from a HD standpoint but is still fighting, but IME this is very rare and not the norm of this type of patient. depends on the surgery and the patient of course, but my thinking is that LMA is indeed gentler and simpler and can offer advantages at times vs ett even for sick patients, its not just a lazy inferior airway

 

[vector2]

I disagree with #1. I feel I can slip in an LMA with next to nothing compared to doing DL/Paralysis and feel ETT requires a heavier induction. And then once the LMA goes in they SV themselves nice and smooth breath to breath to a happy place. Very HD Smooth if you dont see a (mostly) inhalational induction in an adult. The gentlest induction there is..

Theoretically you could tube someone with zero induction agent and all paralytic, so the idea that the average careful LMA induction is going to be the "gentlest" induction there is doesn't seem particularly true. Again, fact remains that even if you feel you can slip in most LMAs with next to nothing, there are going to be plenty of people, regardless of how old and sick they are, who require a decent bit more than "next to nothing" or a bit of finagling, especially if they're fat or have a weird tongue or are edentulous or you're out of igels and have to use some piece of sht, etc etc.

Furthermore, I've done plenty of inhalational induction on adults, and I don't find them particularly advantageous or efficient compared to a careful (mostly) IV induction .

#2 is a rarer bird than you are advertising. Usually someone who is old and sick is not going to fight at low vapor concentrations and your complicating the anesthetic by holding that fear and paralyzing them. Yes every once in a while sure you can have someone who cant tolerate the anesthetic from a HD standpoint but is still fighting, but IME this is very rare and not the norm of this type of patient. And in that situation ill just run some neo and give some narcotic. I do use the low anesthetic high paralysis strategy that you have described but only for a handful of very sick cases, i dont treat everyone like that.. because its totally unnecessary for most basic surgeries

Very sick cases were the kind of cases we were talking about? Hence why I used the LVEF 20% with severe MR/pHTN as an example in my prior post.

Regarding the rest of your point, @pgg already laid out my thoughts in the post right above yours.