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!
Thanks for a fantastic term so far. The Gasclass Team have learnt loads so it must have been good. We have taken our total of views on the Gasclass Blog over 11000 and if only someone in China could see it we could cover the globe. this is truly a worldwide anaesthesia class.
This week we are starting off in the field….literally.
You are watching the local Under 17 Rugby team playing their nearest rivals. There are some wonderfully timed tackles going in but the referee has called the game to a halt. Following the last big pitch pile up one of the boys is motionless face down in the mud. The referee calls for some assistance, especially if there is a doctor or anyone else who can help.
For the purposes of North America please substitute American Football or Ice Hockey as you wish. For the rest of the world, you know what we mean.
As you run onto the pitch what are you thinking?
He is now turned over by you and four helpers, whilst maintaining in line immobilisation. He seems a little dazed but obviously in pain. A brief review shows an obvious deformity of his right lower leg. It is an easy decision that he needs removed from the pitch and the spine board is brought down from the club shed. After removal a helpful local doctor who was watching the Under 14s next pitch says he has a medical bag…….
What in your perfect world would you want him/ her to magic out of this bag?
Just tweet one suggestion!
Lots of great suggestions on the Twitter feed. First and foremost is the suggestion that a phone is the place to start. As long as he has an Ac and a B assessment it is now fairly obvious that he needs to go to medical care. There are many who believe that Ketamine is an excellent choice of analgesic in this situation, but equal proponents of Morphine and Entonox. Clearly the role of potent analgesia must follow a neurological observation.
Assuming his neuro observation is satisfactory and he is compliant:
Which pitch side analgesic do you prefer?
Tweet one word Morphine / Ketamine / Entonox / Other (what exactly?)
We really want some newbies to tweet their preferred choice including non anaesthetists.
The boy has now arrived in the emergency department and it is noticed that he has a white foot.
What is your plan now?
Generally its clear now he needs some kind of treatment and after a temporising manipulation it is decided to move urgently to theatre. The induction proceeds fairly as planned but it seems to be deteriorating some while in.
Ask The Expert….
This week we have asked a new expert Phil who is a Pre Hospital Consultant.
The optimum analgesic agent to give in the pre-hospital environment is open to debate and will depend on the patient as much as the injury. My preference for a closed tibial fracture would be start with entonox and progress to an IV opioid if required. I would normally reserve ketamine for tibial fractures that required urgent manipulation to salvage the foot or the skin integrity. It should be remembered that immobilising and splinting alone can provide excellent analgesia.
Thanks to everyone this week for contributing. Our favourite Tweet was that the Magic Doctor Bag should have an ultrasound machine in it. Ideal!
There are no trick questions in #gasclass. It is an educational tool only. Everyone’s opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialties and you can send us a direct message if you would prefer to remain anonymous.
Welcome to week three of this term. @gasclass is in theatre again this week.
You were called at 1655 on Friday by the Max-Fax SHO regarding a patient on your Monday operating list who has Rheumatoid Arthritis.
What problems do patients with RA pose to an anaesthetist?
Please post one potential problem per tweet and do not tweet again until someone else has put a problem. This should encourage new tweeters to join in.
Thank you for your contributions yesterday.
The patient is a 58 year old lady who requires a radical neck dissection for a neck mass following radiotherapy for a primary SCC base of tongue.
What is your anaesthetic plan? Do you require any specific investigations and why?
You visit the lady. She is on long term steroids for her RA and takes Methotrexate. She is on digoxin for AF. The lady has extensive joint involvement affecting, elbows, wrists, fingers, hips, knees, ankles and feet. Examination of the Respiratory and Cardiovascular systems are unremarkable. Reviewing the imaging and following discussion with the Surgeon there appears to be no recurrance of the base of tongue tumour. The neck mass does not alter the anatomy of the larynx.
FBC – Hb 10.3 WBC 9.4 PLTS 205 MCV 82
U&E Na 140 K 4.1 Ur 3.5 Cr 36
ECG – AF Rate 60
The Max-Fax SHO helpfully arranged the following x-rays.
What are your thoughts now? Does this change your anaesthetic plan? What is your postop plan of management?
Thank you for the contributions yesterday. The patient does have atlanto-axial dislocation as seen above.
You successfully secure the patients airway and the surgery proceeds uneventfully. Post op the patient is admitted to the High Dependency Unit.
Later on the first post-op night the patient develops a right sided neck swelling, becomes pale and stridulous.
What are your thoughts? How would you proceed now?
There are no trick questions in #gasclass. It is an educational tool only. Everyones opinion is as valid as the next person. Follow the conversation by using (or searching for) the hashtag #gasclass on twitter. We welcome input from all specialities and you can send us a direct message if you would prefer to remain anonymous.
This week we start with something pretty straightforward. It’s Monday morning and you see that there is a 10 year old boy listed for bilateral Tendo Achilles lengthening. As you head off to the changing room to get changed what anaesthetic plans will be going through your mind?
With the limited information so far what will you be planning?
You run into your orthopaedic colleague in the changing room (must be same sex) and ask some of the questions that have been raised so far.
They tell you that the operation will be performed supine and that it will be percutaneous approach i.e. not a fully open procedure. It wont take more than 15 minutes to do both sides and they should be able to finish that and the other case on the list which is a pelvic osteotomy before lunch. The patient is a lively character by their estimation. It could be a challenge.
What are your thoughts about premedication?
Now we know what everyone thinks about premedication. You are now actually with the child. He is 10 years old with a diagnosis of Autistic Spectrum Condition. He has challenging behaviours and is not able to attend mainstream schooling. His mother is with him and says that he can get very upset with new people that he doesn’t know. He last had an anaesthetic at 2 years old for a diagnostic MRI when his behaviours were first noted to be causing concern.
He walks a bit on tip toes and has had falls. The orthopaedic team are fairly convinced that they can improve his mobility and this is a reasonable indication for surgery.
Does any of this change your thought process so far? What are your main concerns?
Further update. He refuses oral premedication on the ward but happily comes with his Mother to the OR. He comes into the Anaesthetic Room and hesitantly sits on the trolley. There is absolutely no way he is agreeing to a cannulation and tucks his arms up tight.
Plan A has now gone, plan B seems obvious but we want to explore how far to push it and if you have a plan C. How far can you force a gas induction? What else will you do and why?
Thanks for all the input this week. It has been a great multidisciplinary effort and revealed a somewhat different approach from paediatrics and anaesthetics. It is a fairly common event for a paediatric anaesthetist to deal with the combative child. Advice from the print media is available http://t.co/M8EoEnSD and reinforces the tweet stream from the discussion.
Induction of anesthesia in a combative child; management and issues
Article first published online: 11 APR 2005
Volume 15, Issue 5, pages 421–425, May 2005
A developmentally delayed, 13-year old autistic boy required management of multifocal cerebral and pulmonary tumors, involving several anesthetics over a 4-month period. At each anesthetic he refused premedication, displayed increasing anxiety and became more combative. With parental guidance and involvement, a variety of anesthetists tried a range of techniques to achieve induction, each ultimately resorting to the use of physical restraint. Principles essential to the care of such a child include early recognition, parental support, multi-disciplinary planning of procedures requiring general anesthesia, continuity of anesthesia care, and clear guidelines about the perioperative management of uncooperative children, including the ethical use of restraint.
There are no trick questions on #gasclass. It is an educational tool only so please feel free to join the conversation. Remember to include the phrase #gasclass in your response. This is referred to as a ‘hashtag’ and you can easily follow the conversation by searching for ‘#gasclass’ in your twitter client. We are really keen on some new contributors and especially welcome Core Trainees and Pre Fellowship STRs. Feel free to pose questions to some of the more senior tweeters!
Happy New Year to everyone and welcome to our new term.
Firstly, thanks to all those who filled in our short survey. It has been very useful for us to know that we are widely read although we have some shy followers who are reticent about tweeting. For those of you who haven’t filled in our minuscule survey please follow this link
The case for this week
You are asked by the orthopaedic surgeon to see a 71 year old lady who is due to have hand surgery. He has asked you to see her in outpatients with a view to bringing her in the following week for her operation. Setting off towards OPD what thoughts cross your mind?
What do you see as your default anaesthetic technique for hand surgery?
You arrive in OPD to see the patient. The hand surgery is for Dupuytrens contracture which is fairly extensive and disabling in her dominant hand. The reason that the orthopaedic surgeon has asked for you to see the patient is that she was recently admitted with breathlessness and the diagnosis was exacerbation of COPD.
Will this change your anaesthetic plan?
You are now able to see the patient. Your fears about why an orthopaedic surgeon would notice respiratory risk are well founded. On questioning the patient has an exercise tolerance of about 10m on the flat around her bungalow. She takes prednisolone 5mg daily for her chronic obstruction, as well as a full therapeutic set of inhalers.
The F2 has helpfully done some gases on air. pH 7.38, PO2 7.9, PCO2 6.4, Bicarbonate 35
Her CXR has been reported six months earlier as showing bulbous emphysema, with apical bullae
predominating on the side of operation.
Does any of this change your current plan?
It doesn’t look like this changes too much for most people. Those that prefer to choose one technique preferentially still want to choose that. Having consented the patient for your chosen anaesthesia she leaves the clinic.
Sadly the combination of poor mobility, steroids and a fall the following weekend land her on your trauma list with a fractured humerus for a hemiarthroplasty on the same side as her proposed hand surgery.
What will you do now? Your options are looking much more restricted!
Thanks everyone. A good start to the term with 200 or so hits on the blog this week. The general feeling of RA versus GA did not really shift too much across the case study. Those who would be delighted to block for hand surgery were almost equally delighted to opt for regional for shoulder surgery despite, or even because of, the respiratory issues.
The joy of Twitter as a discussion forum is that the experience of the anaesthetist cannot be guessed from the discussion in the way that a departmental meeting may show that those with grey/no hair may have been happier to just get on with a GA.
We hope that this will encourage those who read the discussion, but don’t Tweet, to join in and especially ask questions of the proponents. If you haven’t already completed the micro survey please link here.
Transcript #gasclass – Term 2 Week 1
See you next week.
There are no trick questions on #gasclass. It is an educational tool only so please feel free to join the conversation. Remember to include the phrase #gasclass in your response. This is referred to as a ‘hashtag’ and you can easily follow the conversation by searching for ‘#gasclass’ in your twitter client.