Term 2 Week 7 (w/c 27/02/12)
Back to the operating theatre this week. The operating list has four patients for lumbar microdiscectomy on it. To get the ball rolling we would like a list of complications for prone positioning related to any surgical procedure.
You should only put one complication per tweet and do not tweet again until someone else has put a complication. This should encourage new tweeters to join in.
The clinical details will follow tomorrow.
One complication of prone positioning per tweet
We now have a fairly comprehensive list of complications for prone positioning. The first patient on the list is a 58 year old male with a left sided disc protrusion. He is 168 cm tall and weighs 97 kg. He has had diabetes for 6 years for which he takes Insulin and Metformin. He normally has controlled hypertension taking Lisinopril and Atenolol although his BP this morning is 157 / 96. He stopped Aspirin treatment one week ago on the instructions of the surgeon.
He has had surgery and anaesthesia previously for pilonidal sinus 14 years ago which was unremarkable, no known drug allergies and denies other systemic illness on direct questioning.
Investigations including U&E, FBC and ECG are unremarkable. His HbA1C is 7.8.
Please answer either of these two questions
1 Is there anything else you want to know?
2. Which of the prone complications do you think should be mentioned?
Some are interested in more information. For the purposes of proceeding there are no further risk factors identified. The airway looks straightforward, Mallampati Grade 1 with reasonable neck movement and mouth opening. His exercise tolerance is a quarter of a mile to the pub and back without difficulty, at least until the recent problem. He admits to 7 pints of beer a week.
3 Does this alter your plans?
4 What will you tell the patient?
Here is the record
What do you think the anaesthetists should do next?
In line with a good viva answer the first step everyone has to go through is establishing internally something fairly serious is going wrong. Regardless of grade asking for help whilst telling surgeon that something bad is happening is part of teamwork. This is the Human Factors bit.
The ABC approach with the 100%O2 is a great start. (Don’t forget anaesthesia or this will be your first report for NAP5 if they recover.) The classic problem here is the prone position. Prone positioning makes just about everything impossible especially CPR. Plans should be made as quickly as possible to turn patient back onto the trolley that you have kept by the door for this eventuality.
With the surgical site packed and the patient supine you establish that the patient is hypovolaemic unresponsive to fluids on the basis of poor peripheral perfusion, tachycardia, persistent hypotension and low end tidal CO2. The airway pressure is 28mBar. This still isn’t clear!
What will #gasclass do next?
The purpose of the case discussion was to discuss two main issues. What can go wrong with prone patients and prone surgery? and What do you do when it has gone wrong?
Diagnosing what exactly the disaster unfolding is not going to be easy either in real life prone position or when a writing about a patient in the prone position. The physiological variables certainly reveal a falling cardiac output and coupled with a dropping haemoglobin the diagnosis of blood loss and the need to ‘turn of the tap’ necessitates hunting for the source and it is most probably abdominal.
Loss from intraabdominal vessels including aorta, IVC and iliac arteries is something that has been noted a number of times by the group experience of gasclass and spotted by @gascast.
We can consider the case closed now and this has been an excellent discussion.
Thanks from @Gasclass. It’s been an excellent week. Next week we are in pain!
Transcript click here