Term 4 Week 1 (w/c 3/09/12)
Welcome to #Gasclass.
It’s been a long summer break. The team have been busy collecting new cases and also gathering some new ideas to help achieve more interaction with the whole class!
We are starting the year off with a case in theatres.
A 21 year old man is on the plastics emergency list for toilet and suture of glass wound to forearm. The only Preoperative information is a history of intravenous drug misuse.
What additional information will you be looking for during your preoperative visit?
Thanks for all the comments. Generally the drug misuse seems difficult to quantify and difficult to make sensible decisions about. However we all recognise the problems are going to be initially venous access and a heightened awareness of infectious risk, although that may be present in other more hidden cases.
The plastic surgeons feel that there is extensive nerve and tendon damage and expect a three hour case. He is fasted 6 hours and on direct questioning he has taken 30 mls of methadone last night as per his prescription. He also admits to some subcut heroin shortly before he put his hand through a house window. He is fairly open about his drug use and does not have any other health related issues. He thinks that venous access is likely to be difficult!
What plans do you wish to make for this case and how will you proceed once in the anaesthetic room?
Lots of debate today concerning the varied techniques that could be depolyed to find venous access. Assuming that your assessment is that the aspiration risk is low we would like to ask how many of you would consider inducing anaesthesia by non intravenous means before looking for a vein.
The circumstances are:
You cannot (including the patient) see a usable vein. The aspiration risk is low. (Please continue to vote despite the case update)
The poll results are definitely interesting. The majority are happy with a gas induction and no venous access. Obviously, no plan survives every situation so…….
What further features would frighten you off this particular plan?
This is also a chance for the No vote to say why they would not proceed at all without knowing that some kind of venous access is secured.
The final part of the jigsaw!
You are in the anaesthetic room with a clear plan of action regarding venous access and possible methods of induction. You connect up the monitors. Saturations are 98% in air, the BP is 115/70 and the monitor strip is as recorded below.
What differnce does this make and what will you do differently?
He has WPW, with an accessory pathway transmitting periodically. On closer questioning he has has some funny episodes where he may have passed out but he put it down to chaotic lifestyle and drug use. Let’s assume venous access with a 24g in his foot has been found. Now….
What are your choices?
It’s been a good week on #Gasclass Thank you to everyone who has joined in with the conversation and the voting.
In summary this is unfortunately a common kind of scenario for Healthcare in urban centres. Patients presenting with dreadful venous access pose a number of different conundrums. Persisting in attempting to locate a tiny peripheral vein is a decision that is only taken in the heat of the battle. However the thought process about what to do next is one we have attempted to discuss. The majority are happy with the idea of a gas induction and relook after the vasodilation of anaesthesia. However a significant number do not agree with this approach.
The gas induction majority are however easily dissuaded from this approach by other complicating factors such as aspiration risk, airway anomalies and co existent disease that might increase the instability of anaesthesia.
It is surprising that there was no mention of Intra Osseous IO access as a back up plan. The ease of use may make this increasingly familiar to anaesthetists.
Returning to the case, the rhythm strip shows WPW. A helpful tweet suggests that in case reports patients with WPW did not have problems. The evidence is therefore opinion based.
Our on call expert says
Wolff-Parkinson-White syndrome is a rare cardiac arrhythmia. The incidental finding of a WPW type tracing on surface ECG should not precipitate anxiety in the treating anaesthesiologist. Remember that a large number of individuals with slurred (delta) upstrokes in their QRS complexes are completely asymptomtic. These individuals are extremely unlikely to present tachydysrhythmias under anaesthesia. However, there are case reports of anaesthesia induced tachydysrhythmias in patients who are known to have the syndrome.
Some feel that regional or loco regional anaesthesia techniques are preferred for the patient with WPW. My feeling would be that general Anesthesia is inherently safe in these individuals provided they have had a recent cardiac evaluation including echocardiography to rule out structural cardiac disease. I would recommend that the provider be fully prepared to deal with any sudden onset dysrythmia – I’d tell my registrars to have Adenosine and lignocaine available immediately and a defibrillator in theatre. Avoidance of stimulation during light planes of anaesthesia should prevent increased sympathetic tone which may precipitate the re-entry tachycardia.
If re-entry did develop I’d suggest a combination of vagal manoeuvres and drug therapy as per standard guidelines, with attention to correction of any electrolyte disturbances. Further, I don’t think any extra interventions are required. I would press on…
Thanks @Gasclass Team
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