You are on call for CCU and you accept a patient for transfer: 56M with recent crescendo angina. He was seen in a peripheral hospital where cardiology performed a diagnostic catheterization but did not perform angioplasty. He has a >90% lesion in RCA. He was loaded with aspirin and ticagrelor and transferred with advanced paramedics in stable condition.
On arrival to your unit, he is complaining of on-and-off chest pain, vitals show HR 90, BP 110/80, SpO2 95% on room air. You notice a bulging mass in the right groin where they accessed for angiogram.
What are your concerns at this time?
You’re concerned that this patient with active untreated coronary artery disease may potentially have a significant bleed (including retroperitoneal extension), anemia and hypotension. He’s taken long-acting anti-platelets so any potential surgery may lead to significant bleeding. He is stable now, but the RCA lesion could lead to conduction issues and RV failure, causing hemodynamic instability.
You place invasive monitors and a central line, and you arrange for CT angio to examine the extent of the bleeding. CT shows a pseudoaneurysm with some stranding in the retroperitoneum but no extravasation of IV contrast on CT.
While he’s being transferred off the CT table, he suddenly loses consciousness.
What is your differential diagnosis and how will you manage the situation?
Remember there are no right or wrong answers. Please tag your tweets with #gasclass!
Welcome to a new week of #Gasclass! This week you’re in the anesthesia pre-admission clinic.
The obstetrician has referred a patient for consideration of induction of labour because of worsening shortness of breath in the last few weeks of pregnancy. She is a 34 yo. G5P4 with 3 previous C-sections (first one was for fetal distress). She is currently at 30 weeks gestational age.
How would you assess this patient?
She has had 3 previous C-sections under neuraxial with no significant issues. The last one was 10 years ago. She reports having worsening dyspnea on exertions, orthopnea and PND. She has trouble sleeping flat and has taken to using 2 pillows. She reports no other significant medical issues on review of systems except for a history of rheumatic fever as a child in her home country.
On examination, she is speaking in 4-5 word sentences, HR 115 irregularly irregular, BP 100/60, SpO2 92% on room air. Her JVP is 5cm above the sternal angle, and there is a loud opening snap with diastolic murmur. She has crackles bilaterally and pedal edema.
Blood work shows mild elevations in her LFTs, but otherwise within normal limits.
You decide to order an ECG and CXR for this patient.
ECG shows atrial fibrillation with right sided strain.
CXR shows mild-moderate pulmonary edema.
You want to order an urgent echocardiogram but the patient lives far away and wants to go home to look after her kids.
Is it okay to let her go home and come back for the echocardiogram?
You counsel her that it is not safe for her to go home right now because she is showing signs and symptoms of pulmonary edema. If this is due to mitral stenosis from rheumatic heart disease, then it can worsen very quickly. You’ve pulled some strings for the echo to be done today, and as she is leaving the clinic she turns around and says “Oh by the way, the last few c-sections the anesthesiologists made a big deal of potentially needing a blood transfusion, but I’ve recently converted to Jehovah’s Witness and I must refuse any blood products.”
How would you counsel her now? Does this complicate your other considerations for the 4th c-section?
You’re worried because she has a high risk for placenta accreta/increta and she is at risk for significant post-partum hemorrhage. You discuss various transfusion options and which ones she would accept. She says she will think about it and discuss it with her Elder before getting back to you.
An echo is completed today and it shows moderate mitral stenosis with preserved LV function, dilated LA, and RVSP of 50 mmHg. It could not conclusively say if there was any thrombus in the left atrial appendage.
Would you consult any other services at this point? How would you formulate your anesthetic plan for this patient?
This is a very high risk patient and you arrange for a complex case conference between anesthesia, obstetrics, cardiology, cardiac surgery, neonatology, hematology and transfusion medicine, interventional radiology and bioethics.
You agree to a plan for elective section. She will be admitted to the antenatal ward with telemetry. She will be started on diuretics and beta-blockers for her pulmonary edema and mitral stenosis. Anticoagulation will be started with treatment-doses of low molecular weight heparin. She will be given celestone injections for fetal lung maturation and be placed on bed rest with supplemental oxygen (which may help decrease pulmonary pressures).
The plan is to undergo elective c-section at 34-36 weeks as long as she tolerates it. Some of your anesthetic considerations are:
- pregnant patient: two patients, aortocaval compression, rapid desaturation, “full stomach”
- moderate mitral stenosis with atrial fibrillation, likely some pulmonary hypertension and pulmonary edema
- sinus rhythm is ideal but need to anticoagulate for potential thrombus and will need TEE to verify before cardioversion anyway
- worry about autotransfusion and flash pulmonary edema
- hemodynamic goals for M.S. are to maintain low-normal HR, maintain afterload and preload, contractility and avoid sudden drops in preload or afterload
- would not tolerate spinal or inadvertent spinal from epidural test dose, would not tolerate oxytocin bolus
- high pulmonary pressures means no prostaglandins (e.g. Hemabate) either
- high risk of PPH and placenta accreta/increta/percreta
- optimize preop Hb levels
- meticulous surgical technique
- consider preoperative internal iliac balloons that can be inflated if massive hemorrhage occurs
- potential for gravid hysterectomy
- discuss all contingency plans for massive hemorrhage including aortic cross-clamp
- complication is she is a Jehovah’s WItness
- discuss which products she is willing to accept
- discuss if cell salvage is acceptable
- once again, meticulous surgical technique (not a “learning case”)
- consider tranexamic acid
- discuss plan if baby needs transfusion – have time to obtain court order ahead of emergency and bioethics counsel
- post-operative monitoring in high dependency unit
What do you think of the plan? Is there anything you would add or change?
You are waiting in line at the hospital coffee shop and see the patient waiting in line ahead of you. After getting her coffee she suddenly grabs her belly in pain and promptly collapses on the ground.
What do you do?
You rush to the patient’s side and see that they are breathing and have a pulse, albeit fast and thready. You call for a code blue, and with the help of the code team you put her on a stretcher and rush her to the L&D C-section suite.
The OB says there is some uterine bleeding and the FHR is slow – 80 bpm but present. She is worried about abruption and want to proceed with C/S emergently.
With some fluid resuscitation your patient actually becomes more alert and vitals are HR 100 afib, BP 95/50, SpO2 97% on 10L facemask.
Do you want to optimize her anymore for surgery? What is your anesthetic plan for this emergent C/S?
Thanks for all your responses this week! We move on to the final chapter…
You called for help and the code team arrives. She has a weak pulse but she regains consciousness with a fluid bolus and you are able to rush her up to the obstetric operating room for further resuscitation. The FHR is 80. The OB has noted some vaginal bleeding. She is currently 32 weeks gestational age.
After a short discussion with the team, it is decided to proceed with emergency c-section. You’ve placed an arterial line and two large bore IVs. You have a completed JW blood products form that states that she will accept albumin, recombinant factors and prothrombin complex concentrates, DDAVP, TXA, and cryoprecipitate. Blood bank was notified to prepare products for her.
A second anesthesiologist was called to help as well because of her hemodynamic issues as well being a very complex case. Neonatology was paged for potential resuscitation of the neonate.
Because her LMWH was not held, an epidural could not be performed. A general anesthetic was induced with very careful attention to hemodynamics and a TEE probe was inserted after intubation.
After deliver of the neonate, the obstetrician proceeds to do a hysterectomy and the patient is extubated and transferred to ICU with an estimated blood loss of 1.5 litres of blood.
After 2 hours you are called back to ICU because the patient’s heart rate is 140, and the ICU team wants you to start more analgesics for her.
What do you do?
Thank you to everyone for reading/tweeting about #gasclass this week! Hopefully there will be more “difficult” cases to come in the near future!
In the meantime, here is our Storify summary.
Remember there are no right or wrong answers! Please tag your tweets with #gasclass!
You are on call and asked to see an inpatient consult.
The patient is a 60 yo man who was admitted to cardiology with infective endocarditis. Strep bovis was initially cultured from the blood and he is on IV antibiotics.
What specific disease is associated with Strep bovis endocarditis? What additional tests should be done?
GI was consulted for colonoscopy, and a large rectosigmoid lesion was found. General Surgery was then consulted, and they want to do a hemicolectomy.
What other investigations do you want? What are you concerned about with infective endocarditis?
TTE shows a large pseudoaneurysm in the aortic root with colour flow within the abscess. There is some thickening of the mitral leaflets. LV function is preserved.
CT scans shows the lesion in the rectosigmoid junction. CT brain also shows a subacute infarct.
Lab work showed a moderate hyponatremia (Na 125).
The patient is hemodynamically stable, afebrile, and on broad spectrum IV antibiotics. There is a 2/6 systolic ejection murmur. No Osler’s nodes or Janeway lesions were found. There is no neurological findings and the patient does not ever recall having had a stroke.
The patient is very persistent on having the colon cancer removed, and that the heart valve issue is “getting better” with antibiotics. The general surgeons want to know if they can proceed.
What is your plan?
Your anesthesia consult includes a recommendation for the patient to be evaluated by Cardiac Surgery for consideration of endocarditis repair/replacement.
The decision to treat the IE with antibiotics vs. operate early is a difficult one. One recent study looked at early valve surgery vs. conventional treatment showed some benefit with a composite endpoint.
The patient decides to undergo hemicolectomy / Hartmann’s procedure first, without replacing the valve.
There are no right or wrong answers. Please tag all replies with #gasclass.
Welcome back to another week of Gasclass! Life has been busy and the summer is drawing to a close, and more cases will (hopefully) be coming your way.
Today you’re on call on a weekend and you’re asked to do a B case for a C1-C2 fusion. This middle-aged man had a fall (EtOH related) several months ago and had multi-level C-spine fractures that was treated conservatively (initially with halo fixation and then Aspen collar). However, during his followup appointment and repeat CT scan it was found that his C2 vertebrae had bone resorption and non-union, therefore it was deemed unstable and would need operative fixation.
Important past medical history included previous STEMI requiring 2x BMS, and a residual LVEF of 35% with moderate diastolic dysfunction. He drinks and smokes heavily. He does not have any neurological consequences from his C-spine fracture at this point.
What are your considerations for this case, and how would you anesthetize him?
The surgeons plan on doing a posterior approach, which would require proning the patient.
What is the safest option for c-spine fixation for proning? What special considerations do you have for a prone case?
After placing an awake arterial line, you proceed to induce the patient. The initial view with VL and MILS is a Cormack-Lehane grade 4 (no epiglottis seen). What is your plan?
You remove the VL and BMV the patient (luckily they are easy!) while the RT turns on the bronch. With jaw extrusion and tongue retraction, you cannot identify any recognizable glottic structures with the bronch. Meanwhile, the blood pressure post-induction has drifted down to SBP 60.
What is your next step and plan?
You try to BMV and thankfully he remains easy. You place an LMA that allows for intubation and bronch through that — the cords are easily visible and the trachea is intubated with the bronch. You railroad the 7.5 ETT through the LMA with some coaxing, but you’re concerned that removing the LMA might cause extubation. What are your options to keep the ETT in place?
What is your plan to manage his hemodynamics now and during the case? (remember, his head will be in pins and proned).
Remember to tag your responses with #gasclass. There are no right or wrong answers, and everyone is encouraged to participate!
We’d like to give a big thank you to the fantastic @mjslabbert for facilitating last week’s trauma case. We had a lot of involvement and discussion from some new and old followers.
This week, we will be featuring another guest facilitator. Dr. Clyde Matava is a pediatric anesthesiologist from Sick Kids Hospital in Toronto, Canada, with special interests in medical e-learning, innovation, and technology in practice and learning. He also runs the Pediatric Anesthesia twitter account.
It is Saturday late morning and you are on call. You receive a page from the neuroradiologist who is requesting an emergency (priority 1) MRI for a 7 month old (6.5kg). The child was previously healthy, had good milestones and presented to ER this morning. The parents report that the child stopped moving her left hand yesterday. While concerned, the parents were not particular anxious about this. However, this morning, a few hours after breakfast, the patient had a left sided seizure and what appeared to be weakness of the whole left side. Neurology and neuroradiology are requesting a stat MRI. The patient is awake and responsive with some flaccidity of the left side. There have been no further seizures.
What are the differential diagnoses?
What other information do you require?
What are your anesthetic considerations? What would you do differently for an elective versus emergency MRI for a child?
Thank you for your comments on twitter. So the case started yesterday with a child who had normal milestones but presented with a brief history of a single seizure and what appears to be left sided weakness. The patient requires an MRI.
What are the differential diagnoses?
As @Neil_brain1 alludes to, the differentials list is pretty wide. Unfortunately, this is common in infants particularly with a sudden onset on clinical symptoms devoid of a prodromal phase.
The common issues in pediatric neurology are
Intracranial tumours (supratentorial and subtentorial)
The primary issues for the anesthesiologist are
the presence or risk for raised ICP
progression of pathology such as bleeding, stroke etc
What other information do you require?
Milestones, family history and other symptoms are important, family history of MH.
With a good NPO status, often enough a gas induction, followed by nasal prongs and a propofol infusion will suffice for a routine MRI brain scan. These scans are typically 30-40 mins long.
However this case is an emergency. You are concerned about the possibility of a bleed or a tumour and so ask that neurosurgery be consulted. Neurosurgery confirms that a tumour is possible and they need to take the patient to the OR if this is a tumour. Furthermore, neurosurgery does not rule out the possibility of the patient needing to go to interventional suite if warranted.
A systemic review shows a previously health child with no known allergies, all immunizations are up to date.
The child last are some cereal 4 hours ago.
You examine the patient and note the following:
GCS 12/15 but patient is responsive
Weakness of the left side
HR – 110
BP – 100/50
RR – 30
No IV access
You prepare for the anesthetic.
What is your plan? What are your local practices?
Going forward we will move quickly through the rest of the case.
You decide to do an IV start and modified rapid sequence IV induction in view of food intake 4 hours ago. You have considered also considered starting an IV under oxygen and nitrous oxide or even inhalation induction if the IV start is difficult. A distressed and screaming child during multiple IV attempts may worsen the underlying pathology particularly if it is a bleed.
You get the IV on the first go and proceed to intubate the patient. The MRI proceeds uneventfully, however the scan reveals a right sided grapefruit sized supratentorial tumour arising from the ventricle with midline shift and flattening of the gyrii. The neurosurgeon believe this to be a choroid plexus tumour and needs to removed immediately. They will need the patient positioned supine with head turned laterally. As a passing comment, the neurosurgeon, remarks ‘these really pour’.
You move the patient to the OR. Currently your patient is stable, with one 24 gauge IV line and a size 4.0 microcuffed ETT.
What are your concerns regarding the patient and procedure?
What monitoring will you need?
What potential issues might you face and how are you planning on mitigating them?
Welcome back after the weekend.
At the end of last week, we were faced with a conundrum of consenting proportions. Consenting around MRIs is a key element of providing pediatric anesthesia. Discussions at recent pediatric anesthesia meetings do suggest that consent for GA is obtained for MRI, even-more-so when patients are critical with a worsening condition. True informed consent has a few key components and always involves a patient. In pediatrics, the concepts of parental permission and patient assent (age appropriate) come in to play. A few great articles on this can be found here.
Going back to the case.
Following a lengthy discussion with the ICU, Surgical and anesthesia, Chaplaincy department, the parents provide consent for surgery. The surgeons estimate 4 hours of surgical time.
The patient is lined up with
- 2x 20ga IVs (saph & arm),
- art line
- urinary catheter
- blood/fluid warmer
- underbody body warmer
- maintained on sevo/remi, oxygen and air.
- Frequent Bedside blood sampling for Hb, lytes and gases.
- Low EtCO2
Within an hour of surgery, it is clear there is continuos bleeding from the tumour. The suction has been running continuously and you have been working hard to keep up. The patient has already lost ⅔ of their estimated blood volume. You continue your work for 4 hours and the final tally estimates blood loss at two blood volumes.
How did you manage the patient?
What was your strategy for blood products in pediatrics with large ongoing blood loss?
What is your local institutional practice for massive transfusion cases?
What complications have you seen?
Remember there are no right or wrong answers. Please tag your replies with #gasclass!
Thank your great comments and participation in this case. As we mentioned at the start of the case, the idea is not to lecture, but to share ideas and reflect on the generic issues that a case like this might reveal.
I thought I’d finish with a little summary and conclusion of the tricky decision making steps with regards to a case like this. These comments are my own and based on a bit of experience and background reading. As always, summoning help early and asking the experts and keeping up with relevant evidence base is super important. I am not trying to tell you how to do it, my aim is to get you to think about how you would manage a patient like this if you ever needed to.
If you have any further points please tweet us and remember the hashtag #gasclass so everyone can follow you comments.
Day 1: “Should I stay or should I go”
Day 1 posed the challenges faced by a hospital team when there is an incident near the hospital and whether to proceed to scene or stay in hospital preparing to receive the patient.
This created a wonderful discussion on twitter! Seems the general feeling was that if you have no prehospital experience but can be of great value to the patient in hospital then it is probably better to stay in hospital and prepare. Do not underestimate the prehospital environment. Keeping in mind that early basic bystander interventions without any equipment can be life saving at scene. Depending where you work and the availability of both in and out of hospital resources, you need to weigh up (as always) the risks and benefits (not just for the patient involved in the accident, but also considering the duty of care you have to the patients in your department).
I am not aware that you have a legal ability to attend – this might differ from country to country.
Ethically, I would want to ( but again, not leave my hospital patients unattended)
FYI, in this case none of the hospital staff attended the scene because the EMS arrived rapidly.
Day 2: “Unexpected turn of events”
Day 2 posed the challenges faced when a patient, who arrived really stable in ER suddenly deteriorates. In this case the patient deteriorated in the Radiology Department, which poses additional difficulties as a remote site with likely very little resources. A lonely place to be with a critically injured deteriorating patient.
For me there are several important points:
Even BEFORE the patient leaves the ER to go to radiology, an initial thorough clinical (ideally multi-disciplinary) assessment is paramount. Make sure that you haven’t missed anything and the patient IS indeed stable enough to leave the Emergency Department if that’s the plan.
Careful attention to the mechanism of injury is always essential and integral to the patient’s story. Build a picture of “worse case scenario” and actively look for clues and exclude these.
When a patient suddenly deteriorate, this will be stressful! Be aware of how this will impact on human factors, such as your own confidence, teamwork, situational awareness.
Go back to the basics! ABCD! Stabilise and resuscitate. The pilots have a saying in a emergency in flight. They: Aviate, navigate and communicate (in that order). Yes, the diagnosis is important and reversible causes needs to be addressed, but keep to the system. It can be tremendously stressful when all your mind is doing is asking :”what is going on, what did I miss…?” You might not have missed anything. Some pathology takes time to present itself clinically. Keep it simple, start at airway and work your way through the ABCD
Get the patient back to a place of safety: When stuck in the Radiology Department with a deteriorating critical patient, or on the ward, or in outpatients etc. do not hesitate to get the patient back to resus. Sometimes the scoop and run technique is best. As anaesthetic registrars doing ICU we are often called to see unwell patients on the ward. I have often prioritised a rapid transfer to critical care above prolonged interventions in a less than ideal environment.
Day 3: “Okay, back to resus then”
Day 3 took us back to resus and essentially a “re-trauma call”.
It is important to start again. As said above, stick to your system. Don’t assume anything. Try and pick up on the clues. “what has actually changed?”
Do not be afraid to remove the collar while maintaining c-spine immobilisation manually to assess the neck thoroughly. This might not have been done initially and you could miss clues.
If you are planning to perform emergency anaesthesia on this patient it is important to document all found neurological findings before RSI.
Be aware that although there were no signs of a pneumothorax in the primary assessment, this can also evolve with time and especially if there are rib fractures or in this case “a small but of fluid in the right chest underlying a seatbelt injury” (likely some blood), you need to remain vigilant when converting to positive pressure ventilation.
Alway do a glucose level in any patient who deteriorates!
The decision to RSI:
Several people on twitter suggested at this point on returning to the ER the patient should undergo a emergency anaesthesia with Rapid Sequence Induction.
I think at this point the patient is really difficult to manage, agitated / irritable, has dropped his GCS. The temptation would be to “give him something to calm him down” i.e. sedation and reach for the midazolam. This is a possible course of action, however might render the patient slightly less conscious and potentially compromise his airway and leave you in the limbo situation. It is clear he requires more imaging, likely a transfer to a neuro centre and at this point it is unclear whether he will require surgical intervention. Based on predicted clinical cause, I would probably give the patient an anaesthetic at this point.
Again, intubating combative patients with a possible or assumed head injury (or something intracranial going on) is a challenge in itself. More even so if you are a junior anaesthetist.
Trauma patients in cervical collars who are not starved, agitated, hyper or hypotensive with possible head and chest injuries are not easy anaesthetic customers! It is tricky to assess their airways, pre-oxigination might be suboptimal, you want to maintain cerebral perfusion by not dropping the blood pressure on induction, but at the same time don’t want to increase ICP. Do not embark on emergency anaesthesia without adequate assistance and a robust plan. This is not the time to reach for drugs or equipment you have never used!! Keep it safe and simple.
Spend time preparing kit while maintaining the airway by simple manoeuvres.
Consider using a checklist (I do in any emergency anaesthetic outside of my anaesthetic room).
Optimise your first laryngoscopy. DO NOT leave the collar done up. You cannot intubate someone with a c-collar done up. Open the front of the collar and have someone maintain inline stabilisation. I very seldom put the collar back on after RSI bit maintain neural alignment with blocks, sandbags or towel strapped next to the patient’s head.
If concerned about intracraneal pathology, don’t make it works i.e. prevent secondary brain injury: Prevent hypoxia, hypotension, venous congestion, hypercapnoea, coughing that can dramatically rise ICP…
Use drugs and equipment you are familiar with: If that is propofol and suxamethonium then be it. Let it not be the first time you use ketamine because that is what all the cool kids on twitter seem to use…
And ask for help (early). It might not arrive in time, but it might.
Day 4 “Could it be a traumatic carotid dissection?”
Day 4 threw in a diagnosis: Traumatic carotid dissection. Not something you see every day.
Rightly, everyone stated that all the common reversible causes (tension pneumothorax, bleeding , hypoxia etc.) should first be identified, treated and eliminated as the cause for the polytrauma patient’s clinical deterioration. But remember that you might need to broaden your diagnostic mind and consider something like carotid dissections.
Yes, it is not that common, but several of you twitter-ratie stumbled on it, and I’ve definitely seen it a few times. Although it is rare, it is a definite consideration in this case and should form part of your differential diagnosis. Also, it can take hour and DAYS to develop so it might be the deteriorating trauma patient on the ward that you are called to several days later….
Patients can present with headache, neck pain, facial pain, transient episodes of blindness (amaurosis fugal) partial Horner’s with miosis and ptosis, hemiparesis, necks swelling, pulsitile tints, deteriorating GCS. As many as 20% of patients present with an ischemic stroke without any warning signs.
The additional challenge that this diagnosis offer is that the treatment is anti-coagulation with heparin and then warfarin…and who of us really feel comfortable with anti coagulating an acute polytrauma patient? I know I don’t. Hence managing and excluding bleeding is essential. Weighing up the risks and the benefits is paramount! And involving specialists is definitely required (even if it is for telephonic advice).
Arranging early critical care transfer for this patient might be the best course of action after you’ve addressed what you can. It is unlikely that a CT angio would be available in small resource limited institutions and starting the process early might save time to definitive treatment. Angioplasty and stent placement might be required if a patient has persistent symptoms and contraindications for anticoagulation. Surgery has a limited role but consultation with vascular surgeons, neurosurgeons, interventional radiology and neurology will be helpful.
Your intubated ventilated polytrauma patient gets transferred to a tertiary neuro centre with you as the anaesthetist escorting him by road, you get home at 11pm after what turned out to be a long, long Saturday shift! The patient ends up making a full recovery.
Well, that’s it folks. Hope you guys enjoyed the case and found it useful. As in everything in medicine, everything is a balance between risks and benefits and it’s is seldom easy decisions we face in critical care.
Remember, everyday is a school day!
Till next time!!
Anaesthetics and Intensive Care doctor Oxford UK
Ambulance Pre Hospital Emergency Physician and Helicopter Doctor
Before I have a few hours sleep after my rather interesting nights shift in emergency theatre, I thought I’d post a few links.
Remember, you are never to old to learn or to young to stretch over your horizons or to stubborn to broaden your differential diagnosis. It’s a relatively rare condition, but definitely should alway be kept in mind in high speed motor vehicle accidents.
Here are a few links you could read through. Every day is a school day….
If some of the links aren’t working, try copy and past it into your browser of choice.
Conclusion and case summary bit later.
Hope you’ve enjoyed it so far.