Todays Case

[Noyac]

33 y.o. female just delivered a 34 wk baby 12 hrs ago. She was brought in for acute abd pain and induced for presumed chorioamnionitis. After delivery her pain did not improve and began to worsen. A chest Xray was ordered and the OB noticed what looked like bowel in the L chest. CT confirmed a incarcerated L diaphragmatic hernia. She was scheduled for a L thoracotomy this am. PMH: MVA in '92 with fx spine treated with Harrington rods from T6 - L1. No other significant PMH.
Vitals: BP 122/74 P 95 Sats 92% RR22.

What's your plan?

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[apma77]

put her to sleep with rapid seq and cricoid pressure (still considered full stomach). no epidural due to potential disrupted epidural space secondary to her spine surgery. hotline, bair huggar, +/- cvp, throw in an artline and cruise!
for post op pain do pca

 

[VentdependenT]

Check cbc, bmp, in the am. have a couple unit on hold.

agree with the rapid sequence. I'd go ahead with ROC.

Bronchial blocker. I aint gonna wedge that fat ass DLT through that swampy juicy oropharynx. Confirm it pre and post flip with your fiberoptic.

Big phat IV. Leave the arm out in case you want an A-LINE if they start messin with the lung.

Restricting fluids won't be needed because they ain't gonna be removing lung (or so we hope...adhesions you say? ugggh)

Intercostal block with ropivicaine while asleep in the lat position posterior axillary line. 2 above and 2 below incision dermatome. Or ask the surgeon to throw an ON-Q pain pump thing in the incision.

 

[amyl]

'xcuse a remedial question but I ain't never gonna learn if i don't ask... what's a brochial blocker?

 

[2ndyear]

How about an intrapleural catheter for post op pain?

Amyl,
A bronchial blocker is basically a catheter with a balloon on the end. You put the balloon in the area you want blocked, blow up the balloon and you're on 1 lung. The newer ones are steerable under fiberoptic guidance, just google Univent tube or Arndt bronchial blocker. So in this case, we would put the blocker in the left mainstem, blow up the balloon and block the mainstem. Ventilations will only reach the right lung now.

 

[militarymd]

 

[militarymd]

33 y.o. female just delivered a 34 wk baby 12 hrs ago. She was brought in for acute abd pain and induced for presumed chorioamnionitis. After delivery her pain did not improve and began to worsen. A chest Xray was ordered and the OB noticed what looked like bowel in the L chest. CT confirmed a incarcerated L diaphragmatic hernia. She was scheduled for a L thoracotomy this am. PMH: MVA in '92 with fx spine treated with Harrington rods from T6 - L1. No other significant PMH.
Vitals: BP 122/74 P 95 Sats 92% RR22.

What's your plan?

Neurontin 900 mg po on day of surgery....otherwise..routine thoracic case.

 

[7by11thenout]

Neurontin 900 mg po on day of surgery....otherwise..routine thoracic case.

NOt routine still has pregnancy physiology - fluid shifts, Airway edema (potentially) Full stomach. Cardiovasular changes. still large uterus - breast feeding?

 

[militarymd]

NOt routine still has pregnancy physiology - fluid shifts, Airway edema (potentially) Full stomach. Cardiovasular changes. still large uterus - breast feeding?

Like I said...routine...All that pregnancy baloney they feed you in residency...is just that...baloney.

 

[7by11thenout]

Speaking from personal experience with pregnancy not just as an anesthesiologist you are wrong....


1. Reflux is prominent even early even at 10 weeks certainly at term or near term.

2. Palpatations are common

3. aortocaval compression is real and very distressing if it happens to you

4. anemia is real a HCt of 40 going to 30 whether it is "physiologic" or not does contribute to symptoms.

5. Fluid shifts do occur peripartum aka you go from not being able to see ankle bones to having ankles again,

The reason these patients still do well most of the time is THEY ARE YOUNG and can tolerate these changes, but these changes do occur and are a risk that must be considered. Would it change my anesthestic? between recently pregnant and not pregnant for this thoracotomy? probably not only I would have a higher index of suspicion if there were problems, I'd check a CBC the morning of surgery, and I would consider aspiration risk - not necessarily do a RSI given need for OLV, but I would consider the risk and examine the Airway with respect to her changing physiologic status.

 

[Gator05]

Perhaps not an epidural, why not a paravertebral?

I'd have an A-line in. Pregnancy is a hypervolemic state, not sure how the bowel is gonna look when they push it back in the belly, and while she SHOULD have room...

 

[jetproppilot]

Speaking from personal experience with pregnancy not just as an anesthesiologist you are wrong....


1. Reflux is prominent even early even at 10 weeks certainly at term or near term.

2. Palpatations are common

3. aortocaval compression is real and very distressing if it happens to you

4. anemia is real a HCt of 40 going to 30 whether it is "physiologic" or not does contribute to symptoms.

5. Fluid shifts do occur peripartum aka you go from not being able to see ankle bones to having ankles again,

The reason these patients still do well most of the time is THEY ARE YOUNG and can tolerate these changes, but these changes do occur and are a risk that must be considered. Would it change my anesthestic? between recently pregnant and not pregnant for this thoracotomy? probably not only I would have a higher index of suspicion if there were problems, I'd check a CBC the morning of surgery, and I would consider aspiration risk - not necessarily do a RSI given need for OLV, but I would consider the risk and examine the Airway with respect to her changing physiologic status.

All your points are well taken.

Mil's (accurate) point is they don't change your intervention...hence a routine thoracic case.

 

[VolatileAgent]

Mil's (accurate) point is they don't change your intervention...hence a routine thoracic case.

dude... just... come on... dude. he called it "baloney". i know you're loyal and you want to get your peep's back and show yer a homey and that attendings gotta stick together and whatnot, but come on. "baloney?" is this setting a good example?

jet, please call bull**** when you see it, no matter who it's coming from. this stuff is important. you guys complain about "slackers" entering the field (although i'd argue the exact opposite is true... and you guys should be nervous), and then he sets this kind of example?

please. don't put words in his mouth and/or justify his posts.

 

[GasEmDee]

dude... just... come on... dude. he called it "baloney". i know you're loyal and you want to get your peep's back and show yer a homey and that attendings gotta stick together and whatnot, but come on. "baloney?" is this setting a good example?

jet, please call bull**** when you see it, no matter who it's coming from. this stuff is important. you guys complain about "slackers" entering the field (although i'd argue the exact opposite is true... and you guys should be nervous), and then he sets this kind of example?

please. don't put words in his mouth and/or justify his posts.

Agreed. The level of mutual masturbation amongst certain individuals around here is just incredible.

 

[jetproppilot]

dude... just... come on... dude. he called it "baloney". i know you're loyal and you want to get your peep's back and show yer a homey and that attendings gotta stick together and whatnot, but come on. "baloney?" is this setting a good example?

jet, please call bull**** when you see it, no matter who it's coming from. this stuff is important. you guys complain about "slackers" entering the field (although i'd argue the exact opposite is true... and you guys should be nervous), and then he sets this kind of example?

please. don't put words in his mouth and/or justify his posts.

Review my posts on the plethora of academic teachings that I don't think hold water, Volatile.

I remember a lengthy post I wrote about putting a woman to sleep for a C section when necessary....and how residents are taught the "dangers" of doing this, to the point where their fear of same could affect their performance....

Risks of certain clinical situations should be taught in academia, I agree.

But academia fails in conveying that the risks are VERY LOW if you are a deft clinician.

And yes, volatile, there are many anesthesia myths perpetuated by academia.

I've never used less than a 7.0 tube for a C-section requiring GA.

C-sections requiring GA are just like any other RSI GA, except they desaturate like a morbidly obese person so you have to be quick. And if there is difficulty intubating, a little reverse T-berg and appropriate (read non gastric-insufflating) mask ventilation can be done until you get the tube in. Academia's over-emphasis on parturient aspiration risk is overblown. Pure and simple. To the point of needlessly placing overblown fear in new clinicians...to the point of potentially affecting your performance. Soooo, have you ever heard an academic dude give you an explanation like that for intubating a parturient? I'll bet not. I'll bet they placed fear in your head.

I've yet to figure out why it is taught that an RSI must be done on someone with non-postural GERD.

I've yet to figure out why many clinicians give a pre-op albuterol treatment to an asymptomatic asthmatic.

I think our NPO guidelines need to be modified.

I could go on and on.

Not blindly agreeing.

Just calling it like I see it after ten years making my living in this biz.

 

[militarymd]

Speaking from personal experience with pregnancy not just as an anesthesiologist you are wrong....


1. Reflux is prominent even early even at 10 weeks certainly at term or near term.

2. Palpatations are common

3. aortocaval compression is real and very distressing if it happens to you

4. anemia is real a HCt of 40 going to 30 whether it is "physiologic" or not does contribute to symptoms.

5. Fluid shifts do occur peripartum aka you go from not being able to see ankle bones to having ankles again,

The reason these patients still do well most of the time is THEY ARE YOUNG and can tolerate these changes, but these changes do occur and are a risk that must be considered. Would it change my anesthestic? between recently pregnant and not pregnant for this thoracotomy? probably not only I would have a higher index of suspicion if there were problems, I'd check a CBC the morning of surgery, and I would consider aspiration risk - not necessarily do a RSI given need for OLV, but I would consider the risk and examine the Airway with respect to her changing physiologic status.

As I said, and you just reiterated....routine.

The goals we aim for in the OR is not like threading a needle...more like hitting the broad side of 3 barns string together.

Sure, there are some annoying physiologic differences between this patient and some one else.....

But in the grand scheme of things...it doesn't amount to a hill of ant poop...and it doesn't change what you do....and it SHOULD NOT change your attention to detail......I hope you don't pay less attention to complications just because someone is not peri-partum

like I said...routine...

 

[joshmir]

>Neurontin 900 mg po on day of surgery....otherwise..routine thoracic case.

mil-

what kind of cases do you try to give neurontin on?

 

[militarymd]

>Neurontin 900 mg po on day of surgery....otherwise..routine thoracic case.

mil-

what kind of cases do you try to give neurontin on?

Any case where there is significant post-op pain....right now I use it on back fusions, total joints

 

[7by11thenout]

Any case where there is significant post-op pain....right now I use it on back fusions, total joints

how long do you continue gabapentin? I have heard of some doing this, but at the three hospitals where I have worked none of us have done it. Do you think it really does make a clinical difference or just alter their mental status since you are starting with a pretty high dose. I seem to remember titrating up gabapentin in the pain clinic to ease some of the mental complaints we would get with the drug.

 

[fakin' the funk]

Agreed. The level of mutual masturbation amongst certain individuals around here is just incredible.

Does it count as masturbation if someone else is doing it to you?

 

[MirrorTodd]

That's a handjob for a guy, fingering for a girl. Sorry for the tangent Noy.

 

[militarymd]

how long do you continue gabapentin? I have heard of some doing this, but at the three hospitals where I have worked none of us have done it. Do you think it really does make a clinical difference or just alter their mental status since you are starting with a pretty high dose. I seem to remember titrating up gabapentin in the pain clinic to ease some of the mental complaints we would get with the drug.

Just a single dose pre-op.

It's hard to tell how well it works, but the data that is published does show that patients who get it will require "less" narcotic over the next 24 hours.

 

[Noyac]

Sorry for the absence this weekend (Moab mtn biking).
So here's my thoughts and what I did.
Pt did have significant GERD up until delivery the day b/4 this scheduled case. But that didn't change my approach (no RSI). I figured I'd try a Thoracic epidural and if that didn't work a paravertebral block. I was successful with the T. Epi at T6 without any struggle. If neither the T. epi or the paravertebral block were successful then we would have put a intrapleural cath in after the case and hooked it up to a pump. I also used the epidural forhte case so I knew it was working well.
The induction was no different than any other chest case. Prop. 150mg, Fent. 150 mcg, Roc 50 mg. Mac 3 blade 39 Fr L DBL ETT (personally I like dbl lumen tbes much better than bronchial blockers). Positioned R lat decub and tube placement/lung isolation verified. I did nothing different for her physiology due to recent pregnancy. I also gave 150mg Ketamine, 2gm Mg intra-op. Pt woke up fine and never felt the incision. She complained of some shoulder pain. Chest tube or large diaphragmatic defect repair? Both? Toradol helped.

Routine case! But I knew it would get some discussion going.

 

[EV-Stentor]

Like I said...routine...All that pregnancy baloney they feed you in residency...is just that...baloney.

Hey Mil while I respect your opinions generally and agree that this case is pretty routine I cannot DISAGREE with you more that residency training is baloney. I mean it is okay for you to say the academic fears are over stated but baloney? Common bro lets be polite to one another..If I am not mistaking you were a resident @ some point in your care er