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Summary and conclusion of June Case (Term 8)

June 15, 2014 Leave a comment

Hi Team!

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.

Summary:

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.

Final words:

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!!

docMJ 

Anaesthetics and Intensive Care doctor Oxford UK

Ambulance Pre Hospital Emergency Physician and Helicopter Doctor

 

June Case: Traumatic carotid dissection: Some links you might find useful background reading.

June 13, 2014 Leave a comment

Hi All,

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….

ftp://82.239.144.183/bibli/-%20Revue%20Articles%20FB/Biblio%20120417+0503%20rout%E9e/276.1205-

Cervical%20carotid%20artery%20dissection.%20Current%20review%20of%20Dg%20and%20Tt_Patel,%20Cardiol%20Rev..pdf

www.hkcem.com/html/publications/Journal/2012-1%20Jan/p49-53.pdf

www.ncbi.nlm.nih.gov/pmc/articles/PMC3303245/

https://www.inkling.com/read/vascular-and-endovascular-surgery-beard-gaines-loftus-5th/chapter-9/cervical-vascular-injuries 

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.

MJ

June case (week 8): RTC altered neurology: Summary so far and what’s to come…

June 12, 2014 Leave a comment

Hi All,

Over the next two days our case of the motor vehicle crash victim who developed altered neurology some time after arriving in the ER will conclude. We have already touched on some tricky decisions and situations you might find yourself in:

Day one focused on decision making with regards to attending prehsopital scenes as “in-hospital” medical providers when the proximity to the hospital makes the decision challenging.

Day two focussed on the deteriorating trauma patient in a remote hospital location such as the Radiology Department, but might as well have been on the ward.

Day three focussed on the importance of returning to a place of safety and resources (resus) and the concept of reassessing ABCD, resuscitate and support then diagnose and thorough clinical assessment and broadening your diagnosis. I think important non-technical aspects come into play here such as self-doubt, confusion with regards to diagnosis, fear for your patient’s clinical deterioration, lack of resources in small institutions, the concept of going from  a state of boredom to a state of stress.

Screen Shot 2014-06-12 at 16.48.52

 

 

 

 

 

 

 

 

Day four will focus on solving the mystery, considering the actual pathology found in this case and risks vs benefits of treatment.

Day five: Tomorrow will conclude with safe inter-facility transfer to definitive care / retrieval and discussions / ideas around “best anaesthetic”

….and who said the anaesthetists role is restricted to the OR?

Keep participating.

June case: (week 8 day3): okay, back to Resus then!!

June 12, 2014 Leave a comment

Hi All!

Thank you for everyone’s participation. Remember tag tour tweets with #gasclass so everyone can see it.

So, where were we? Oh yes, ultimate nightmare: The polytrauma patient from the car crash has suddenly deteriorated in the radiology Department, afterhours on a Saturday afternoon in a small intercity hospital. You, as anaesthetic doctor are called by the porter to go and help out. When you arrive the patient is incredibly restless, doesn’t want to lie flat.

Most people on twitter suggested the plan of action should be to rush the patient immediately back to resus.

So, that’s what you do. Radiology in this hospital is quite remote and there is barely an oxygen cylinder about to speak off, so you and the porter rush the patient back to the Emergency Department.  All the way down the corridor you keep on thinking : “What dit I miss, WHAT DID I MISS? What is going on!!??¥$%#

In resus you reunite with your ER colleague and go through another primary survey:

A: Patent, talking but not coherent. C-spine still in collar. Bruising and slight swelling over neck from seatbelt

B: Sats 99% on highflow O2. Bilateral air entry. No pneumothorax on U/S. Small bit of fluid right chest and visible seatbelt sign

C: BP: 160/88mmHg. pulse 108. No blood in abdomen on re FAST. Pelvis still appears intact on examination

D: GCS: E4V3M5  pupils unequal with one pinpoint. Patient not moving his left side. Patient remains restless and uncooperative.

E: Glucose level normal. Minimal bleeding from open elbow fracture right.

Questions:

What’s going on?

What is your course of action?

okay, everyone would probably want to do a CT head right? What if I tell you the plain head CT appears normal…well, to you and your ER colleague at least.

 

happy tweeting.

conclusion and ideas around management of his diagnosis and anaesthetic involvement further to follows.

 

June week case: Day 2: Unexpected turn of events (Term 8 Week 4)

June 10, 2014 Leave a comment

Hi guys!

Excellent comments on Twitter! Remember to use #gasclass so that everyone can follow the comments.  Please continue to read on as the case develops. First a little summary and a few points to ponder.

So yesterday’s case started with a tricky situation: A two car accident occurred on corner streets of your hospital. EMS apparently 10-min away. The main consideration was: Should you go check it out or stay in hospital and prepare for patients arrival?

Here are a few points I was thinking of:

Summon help: Ensure that the local EMS activation number has definitely been dialled. It could be that this has not happened and someone just saw there is a hospital nearby and ran in, expecting or anticipating that the hospital will activate the prehospital providers.  Also consider summoning more hospital resources early. Hopefully even a small hospital has some sort of escalation plan.

Remember, you have an established duty of care to these hospital patient and cannot leave them without sufficient medical care. It might be that you are the only clinician in the hospital and then you definitely can’t leave.

Don’t underestimate the pre-hospital environment. It is unsafe, unpredictable and not kind to novices. Personal protective equipment is essential. Hospital medics in scrubs and trainers are definitely not ideal.Also, take into account, the “jump bag” or transfer kit is not alway fit for purpose in the prehospital environment (what the heck are you going to do with an arterial line transducer on scene…?)

Having said all of that, there are some potentially essential life saving things that can be done in the first few minutes following an incident while EMS is still on route. We know this from the impact bystander CPR has on prehospital (non-traumatic) cardiac arrest cases.

Equally, in trauma cases, secondary brain injury from, for example hypoxia due to an occluded airway can have a dramatic impact on longterm neurological outcome of head injury patients. There are patients who die from potentially reversible causes before the ambulance crews arrive. Simple interventions could make the difference between leading a full live and being severely impaired or worse, death. Some of these simple interventions include: Opening an airway or putting direct pressure on a bleeding wound. You don’t need any equipment for this and could literally save someones life…

I’m not 100% sure there is a right answer to this. Like most things in medicine you have to way up the risks and benefits and try and make the best decision with the information, skills, team and equipment you have.

OKAY, DONT STOP READING NOW, the good stuff is still coming! Lets continue with the case:

So, luckily as you are trying to find the code to the combination lock on the (locked) door to the high-viz jackets and transfer bag, you can hear the sirens of an ambulance (with the prehospital professionals) turning the corner and arriving on scene. (Ambulance control had several calls on the incident and managed to mobilise an ambulance crew nearby.)

Within minutes the EMS crew brings three patients to the ER. Due to the proximity of the accident to the hospital, not too many interventions were done before the patients arrive with you. One patient is the driver of a large German car and he has only minor injuries and declines any medical care. The other two patients are husband and wife from the smaller car that had the side impact to the driver’s side.

The rest of the case will focus on the driver of the smaller car. Lets call him Adam 55.

Brief handover from ambulance crew to your trauma team (i.e you as anaesthetic airway support and whoever is there):

  • 55y/o called Adam
  • 10-min ago two car RTC
  •  Side impact on driver’s side. Was wearing a seatbelt. No clear history of loss of consciousness. Not mobilised on scene. Extricated via side door on an extrication board
  • Injuries found: Neck pain; Tender ribs, good bilateral air entry. Open wound and possible fracture to right elbow. No suspected abdo, pelvis or other long bone injuries.
  • Prehospital treatment received: Reassurance, spinal immobilisation with cervical collar, head blocks and on a hard board.
  • GCS 15/15, moving all four limbs. Pupils equal and reactive. Vitals stable last 10-minutes.

The team do a thorough systematic evaluation (CAcBCDE) and confirm the above findings. eFAST negative. Portable pain chest X-ray and pelvis X-rays are normal. Observations within normal range. As an anaesthetist at this point you decide that your services are no longer required in the ER and this has been far to much excitement for a Saturday afternoon and you retreat to the coffee room – topping up on caffeine in anticipation of this patient potentially needing some sort of surgery for his elbow injury later.

In the mean time your Emergency Room colleague sends the patient to the X-ray Department at the back of the hospital for his elbow X-ray. No trauma CT done. To get a weekend CT in this hospital the CT radiographer needs to come in from home.

20-minutes later an out-of-breath hospital porter tracks you down in the coffee room and says: “Doc, the ER doc needs you to urgently go to the X-ray Department! That patient is now ‘not quite right’. That man is making no sense, doesn’t want to lie flat, looks like a ‘dear staring into headlamps’. The ER doc is dealing with the other lady patient and can’t go. Come!!”

You follow the porter to the rather remote X-ray department to find the radiographer physically trying to keep the patient on the bed. He is combative, and slurring his speech.

Questions:

  • What’s going on? What could have led to the change? 
  • Think of a differential diagnosis and how you would exclude or confirm it.
  • What’s your course of action?
  • What are the potential obstacles / challenges you might face to achieve this?

 

Remember, tweet your comments tagged to #gasclass and myself or the gasclass bloggers will try and retweet and reply to it. The aim is to generate discussion and learn from one another.

Look back at the blog regularly – it will get updated.

More to follow later…

 

Term 7 Week 4 (w/c 28/10/2013)

October 28, 2013 Leave a comment

We’ve escaped the community and are back in theatre this week. You are the cardiac anaesthesia registrar, slated to cover Paeds Cardiac Surgery this week. Your first case tomorrow is an 8month old girl who is booked for a Blalock-Taussig Shunt.

Her diagnosis is listed as Tetralogy of Fallot.

What information would you like to elicit in order to help you manage this child peri-operatively? 

Some interesting questions asked yesterday, thanks for the input. Most have concentrated on the degree and nature of the cyanosis, which is entirely appropriate.

You see the child. She is 8 months old, weighs 5.2kg and at rest, she is not cyanotic. The mother reports that she was born at term, was discharged routinely from hospital but soon after birth mom noticed that the child became discoloured during feeding and when she cries. She was seen and assessed at age 2 months as a tetralogy of Fallot, shunting was recommended but the pair were lost to followup until recently.

The cyanotic episodes are becoming more frequent and they are limiting the ability of the child to feed. The mother also reports that the child has “fainted” on one or two occasions. In terms of medical therapy, the baby is on a beta blocker (inderal). Mom reports that this has helped somewhat.

The child has had an evaluation by the paeds cardiology team who have demonstrated the typical findings of tetralogy of Fallot – RV hypertrophy, over-riding aorta (50%), VSD and infundibular narrowing (RVOT obstruction). During spelling the gradient across the infundibular obstruction was noted to be 50mmHg.

What are some of the relevant sequelae of ongoing cyanosis, wherever it’s clinical context? (child, adult)?
How should we manage these in this scenario?

Remember all input is welcome. yesterday was decidedly top heavy on the consultant side. In many countries, a thorough working knowledge of the management of this disease is expected of candidates for the specialist exit exam!

After assessing the child, you decide that you are happy to proceed. The Hb is 18g/DL and renal function is normal. The child is first on the theatre list for tomorrow. It is booked for left thoracotomy and modified BT shunt with a goretex graft from left subclavian to left pulmonary artery. What is the anaesthetic plan?

You have the child in theatre, induction has gone smoothly and the tube is in. As you are preparing for arterial line insertion, you notice a fall in ETCO2 and the saturation begins to drop.

What is your immediate plan of action?

A brief summary of the issues will follow tomorrow.

Thank you for the input this week. What follows is a brief summary of how I approach the child with a tetralogy of fallot. It represents nothing more than a personal approach, a rubric that works for me. Comments welcome.

 

Tetralogy of Fallot is a congenitally acquired cardiac condition characterised by right ventricular hypertrophy, a sub membranous VSD, overriding aorta and infundibular spasm. It can be categorised as a cyanotic defect, with low pulmonary blood flow.

 

Children usually present early with a history of cyanosis and hyper cyanotic spells, exacerbated with feeding and crying. Those who do not present early develop and are often seen to adopt the classical squatting pose to break the cyanotic spell.

 

Surgical management is usually directed at increasing pulmonary blood flow, initially with a palliative procedure, some variation of a Blalock Taussig shunt whereby pulmonary blood flow is augmented by draining the left subclavian artery into the left pulmonary artery. This is done to provide relief from the hyper cyanotic spells, and to “mature the pulmonary circulation” to a level where complete correction can be undertaken, usually at age 3-4y. 

 

From an anaesthesiology point of view, these children provide a challenging opportunity. They are often underweight, with tenuous right ventricular function. The ongoing cyanosis is exacerbated by polycythaemia and many of the comments this week alluded to this. polycythaemia leads to increased viscosity of the blood with sluggish cerebral blood flow, worsened in states of dehydration. If the child is symptomatic or has had some sort of cerebral event preoperative venesection can be considered to reduce Hb to more manageable levels, although this is (in our setting) rarely done. The polycythaemia also has functional effects on coagulation, the hyper coagulability mentioned above is one issue. The other is that platelet function is suppressed and these children may exhibit increased surgical bleeding. The effects of the polycythaemia are exacerbated in the presence of dehydration so limit starvation time to 6hours for solids and 2 hours for liquids. The parents should be encouraged to give the child fluid right up to the 2h mark. 

 

For those preparing for examinations, the controversial aspects in the management of Tetralogy patients coming for surgery are (a) whether or not to premeditate and (b) IV or gas induction. 

 

Premedication presents a double edged sword. On one hand, the premeditated child is less likely to cry and struggle on induction which is advantageous as these may increase the likelihood of a hyper cyanotic spell. However, the heavy premedication required to prevent this may present the risk of respiratory depression, hypercarbia and hypoxemia. Premedication in the ward is not recommended. If your pre op holding area is monitored and access to pulseoximetry is easy, then premedication is reasonable. In my practice I typically do not premedicate. I have spoken to anaesthesiologists at major children’s hospitals and some recipes for premedication include Midazolam 0.5mg/kg PLUS Ketamine 7.5-10mg/kg po. I’m told the children are very compliant at this dose and tolerate IV insertion. Your mileage may vary but you’d need very well monitored holding areas for this technique, remembering that his cocktail can take up to 45minutes to work.

 

On choice of induction technique, the recommended approach is to establish IV access and do an IV induction. Again agents of choice are controversial. Ketamine probably represents the best option as these children generally are not in extremis and a conventional dose will maintain systemic vascular resistance, and augment contractility, which should limit right to left shunting. Induction with propofol is not recommended. A high dose opiate induction is also a reasonable approach. If IV access is available then a preload with 20ml/kg prior to induction will be helpful.

 

Typically, our practice is to perform a gas induction with Sevoflurane. The problem with this approach is that on gassing is dependant on adequate pulmonary blood flow which is obviously not present in this scenario. We take over ventilation early in order to prevent the breath holding that occurs during second stage (which feels like a very long time in these children) and the resultant hypercarbia.

 

Monitoring is with arterial and central access in the contralateral side. Surgery is done via a high left sided thoracotomy. The vessels are side clamped so there is no interruption in the limited pulmonary blood flow. On opening of the shunt there may be an element of reactive pulmonary hypertension due to the acute increase in flow. Analgesia is via opiates and intercostal nerve blocks. There is always potential for disaster (rupture/tearing of the vessels) and the bypass machine should be ready to run if not primed. 

 

In terms of a broad approach to cardiac defects in children, a wise man once taught me this approach, a rubric, if you will.

Draw the anatomy – not in Frank Netter detail, but what we call a “box diagram”

Trace the path of the red blood cells, it sounds trivial, but draw it on your box diagram. It will give you a good working idea of the functional physiology of the defect.

Think. What is the effect of changes in downstream resistances? What will increasing SVR or PVR have? Decreasing?

What could go wrong? I.e what are the potential disasters

How will you manage these if they occur?

TOF diag 

 

Now we know the anatomy, and the red cell path, we can look at 3, the effect of changes in downstream resistances.

SVR up leads to decreased R to L Shunt, the converse happens when SVR drops, like during an IV induction with Propofol or a careless gas induction

 

PVR increases worsen hypoxaemia. Decreases in PVR have little clinical effect because the RVOT obstruction usually limits flow.

 

Next, what can go wrong? In this case, a hyper cyanotic spell. How do we manage this? Physical maneuvers like flexing the hips or compressing the femorals increase SVR and limit right to left shunting. The same effect can be achieved with phenylephrine/neosynephrine. I usually draw up before hand, a few syringes with phenyl diluted to 1mg/kg/ml. I chase these with boluses of fluid (used to use colloids but now not so much) of 10-15ml/kg which seems to stent open the RVOT.

 

 

So this is a quick and dirty approach to TOF. The same rubric could be applied to any congenital cardiac condition.

Term 6 Week 2 (w/c 06/05/13)

Wecome to this weeks #gasclass.
You are  helping in the pre-assessment clinic. Your next patient is a a 68 year old man who is listed for an open cystectomy and formation of ilieal conduit.

To start this week  – What are the potential surgical / procedure issues relevant to an anaesthetist?

Thank you for all your comments so far. We all agree that it will be a long case and has the potential for major blood loss.

The patient attends the clinic. As he walks into the room you hear an audible wheeze.

He is a retired chemist and ex 40 pack year smoker.  He is 85kg and Height is 1.76m.

PMH include hypertension and type 2 DM.

What are your thoughts? What else would you like to know & what investigations will you order?

Thank you for comments yesterday. Further questioning reveals a gradual onset of SOB over the last 6 months. His exercise tolerance has not been reduced, although he comments that it now takes him longer to walk the same distance to the shops. He sleeps on 2 pillows. BP 176/88  P85 reg CXR is unremarkable.  ECG shows NSR with mild LVH

Hb 110g/l WBC 5.3 PLTS 150 Na 130 K 3.6 Ur 7.8 Cr 120 HBA1C 8.9

What else would you like to know? What is your anaesthetic plan?

We had a few  thoughts and ideas yesterday.

His PFTs reveal an obstructive pattern with an FEV1 of 1.2L His echo revealed moderate LVH and mild LV systolic dysfunction.

You discuss with him the options for anaesthesia and he agrees to have an epidural followed by GA with invasive monitoring.

A week later the man arrives in your anaesthetic room. You insert the epidural and induce anaesthesia. During the procedure there is suddenly major blood loss ~2L and he develops ST segment elevation and hypotension.

What are your thoughts now and what are you going to do?

Please remember to add the hashtag #gasclass to all correspondence on Twitter. Please also take turns to put your thoughts. Try to keep to one issue and then wait until another Tweeter has contributed before giving more thoughts.

Everyone’s views are welcome. We really would like to welcome more contributions this term so new people are very welcome whatever your background or grade.

The Gasclass Team

The Storify summary for this weeks case can be found here

SUMMARY