Term 2 Week 5 (w/c 13/02/12)
9You are covering the emergency list. The next patient is a 31 year old lady booked for a groin exploration. There is a note on the computer system that she is an intravenous drug abuser.
Prior to visiting her, what are your thoughts about anaesthetising her?
You set off to the ward to perform a preoperative visit. In doing so you realise she is actually on the maternity ward. Further conversation with the surgeon reveals that she is approximately 34 weeks pregnant. She has attended some antenatal care and as far as he knows she hasn’t had any problems until now. He tells you that she has been in hospital for the past 24 hours having presented with pain in her groin and back. She has had a temperature and appears mildly septic. MRI confirmed a pregnancy in third trimester as well as an extensive abscess extending up towards the psoas muscle. He feels she needs source control as part of her treatment for sepsis.
Now what are your thoughts regarding anaesthesia and her care?
The patient declined spinal or epidural anaesthesia as she didn’t want a needle in her back. You proceed with general anaesthesia for caesarean section and debridement of the abscess. Both mother and baby go to respective high dependency areas postoperatively.
On day 3 postop it is flagged up to you that the patient states she ‘was awake’ during the surgery.
How are you going to proceed?
This weeks case was a complex one, featuring multiple issues. Initially we were presented with the problems of intravenous drug abuse. Obvious points were raised such as poor IV access and the risk of blood borne viruses. Several other valid points were made such as immunocompromisation, nutritional issues and how trust worthy the patient was likely to be? An untrustworthy patient was felt to present problems such as absconding or being untruthful regarding fasting for example. The majority of the initial discussion focused quite rightly on the difficult analgaesia in these patients.
The next clinical dilemma arose when we found out that the patient was pregnant. We were told that the patient was 34 weeks and the view from the twitter feed was that caesarean section should be performed at the same time as groin exploration. In the classroom based discussion the point was made that IUGR was a possibility given the other problems and that this would need close discussion with obstetricians and neonatology.
There was a split of opinion regarding regional versus general anaesthesia. In the presence of systemic sepsis most felt an indwelling epidural catheter was not a good idea. The supporters of single shot spinal argued that it would facilitate better pain control. Those in favour of general anaesthesia were concerned over duration of surgery and the possibility that debridement of the psoas might encroach on the upper limit of sensory block causing discomfort. Nearly all supported the suggestion of HDU post op for both mother and child as there was significant potential for sepsis and difficulty with analgaesia.
The final aspect of the case focused on a potential incident of awareness. In a patient claiming to be awake, the first step is to visit the patient and determining exactly what they mean. Is this simply someone remembering extubation or is there explicit awareness, if so is there pain? A variety of other relevant suggestions were raised such as escalation to senior clinicians early, taking a colleague to the patient interview and the offer of psychological support for the patient. A review of technique and confirming that there was no equipment malfunction are also sensible suggestions. An appology should be offered and it was noted that doing so does not admit blame or negligence.
Finally the issue of BIS was as contentious as ever. A recent NEJM paper was quoted but the main supporters highlighted some of the paper’s shortcomings as well as claiming that BIS remains a preferred option in those using TIVA or in the abscence of end tidal anaesthetic gas monitoring.
More next week….
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