You are on call for CCU and you accept a patient for transfer: 56M with recent crescendo angina. He was seen in a peripheral hospital where cardiology performed a diagnostic catheterization but did not perform angioplasty. He has a >90% lesion in RCA. He was loaded with aspirin and ticagrelor and transferred with advanced paramedics in stable condition.
On arrival to your unit, he is complaining of on-and-off chest pain, vitals show HR 90, BP 110/80, SpO2 95% on room air. You notice a bulging mass in the right groin where they accessed for angiogram.
What are your concerns at this time?
You’re concerned that this patient with active untreated coronary artery disease may potentially have a significant bleed (including retroperitoneal extension), anemia and hypotension. He’s taken long-acting anti-platelets so any potential surgery may lead to significant bleeding. He is stable now, but the RCA lesion could lead to conduction issues and RV failure, causing hemodynamic instability.
You place invasive monitors and a central line, and you arrange for CT angio to examine the extent of the bleeding. CT shows a pseudoaneurysm with some stranding in the retroperitoneum but no extravasation of IV contrast on CT.
While he’s being transferred off the CT table, he suddenly loses consciousness.
What is your differential diagnosis and how will you manage the situation?
Remember there are no right or wrong answers. Please tag your tweets with #gasclass!
Welcome to a new week of #Gasclass! This week you’re in the anesthesia pre-admission clinic.
The obstetrician has referred a patient for consideration of induction of labour because of worsening shortness of breath in the last few weeks of pregnancy. She is a 34 yo. G5P4 with 3 previous C-sections (first one was for fetal distress). She is currently at 30 weeks gestational age.
How would you assess this patient?
She has had 3 previous C-sections under neuraxial with no significant issues. The last one was 10 years ago. She reports having worsening dyspnea on exertions, orthopnea and PND. She has trouble sleeping flat and has taken to using 2 pillows. She reports no other significant medical issues on review of systems except for a history of rheumatic fever as a child in her home country.
On examination, she is speaking in 4-5 word sentences, HR 115 irregularly irregular, BP 100/60, SpO2 92% on room air. Her JVP is 5cm above the sternal angle, and there is a loud opening snap with diastolic murmur. She has crackles bilaterally and pedal edema.
Blood work shows mild elevations in her LFTs, but otherwise within normal limits.
You decide to order an ECG and CXR for this patient.
ECG shows atrial fibrillation with right sided strain.
CXR shows mild-moderate pulmonary edema.
You want to order an urgent echocardiogram but the patient lives far away and wants to go home to look after her kids.
Is it okay to let her go home and come back for the echocardiogram?
You counsel her that it is not safe for her to go home right now because she is showing signs and symptoms of pulmonary edema. If this is due to mitral stenosis from rheumatic heart disease, then it can worsen very quickly. You’ve pulled some strings for the echo to be done today, and as she is leaving the clinic she turns around and says “Oh by the way, the last few c-sections the anesthesiologists made a big deal of potentially needing a blood transfusion, but I’ve recently converted to Jehovah’s Witness and I must refuse any blood products.”
How would you counsel her now? Does this complicate your other considerations for the 4th c-section?
You’re worried because she has a high risk for placenta accreta/increta and she is at risk for significant post-partum hemorrhage. You discuss various transfusion options and which ones she would accept. She says she will think about it and discuss it with her Elder before getting back to you.
An echo is completed today and it shows moderate mitral stenosis with preserved LV function, dilated LA, and RVSP of 50 mmHg. It could not conclusively say if there was any thrombus in the left atrial appendage.
Would you consult any other services at this point? How would you formulate your anesthetic plan for this patient?
This is a very high risk patient and you arrange for a complex case conference between anesthesia, obstetrics, cardiology, cardiac surgery, neonatology, hematology and transfusion medicine, interventional radiology and bioethics.
You agree to a plan for elective section. She will be admitted to the antenatal ward with telemetry. She will be started on diuretics and beta-blockers for her pulmonary edema and mitral stenosis. Anticoagulation will be started with treatment-doses of low molecular weight heparin. She will be given celestone injections for fetal lung maturation and be placed on bed rest with supplemental oxygen (which may help decrease pulmonary pressures).
The plan is to undergo elective c-section at 34-36 weeks as long as she tolerates it. Some of your anesthetic considerations are:
- pregnant patient: two patients, aortocaval compression, rapid desaturation, “full stomach”
- moderate mitral stenosis with atrial fibrillation, likely some pulmonary hypertension and pulmonary edema
- sinus rhythm is ideal but need to anticoagulate for potential thrombus and will need TEE to verify before cardioversion anyway
- worry about autotransfusion and flash pulmonary edema
- hemodynamic goals for M.S. are to maintain low-normal HR, maintain afterload and preload, contractility and avoid sudden drops in preload or afterload
- would not tolerate spinal or inadvertent spinal from epidural test dose, would not tolerate oxytocin bolus
- high pulmonary pressures means no prostaglandins (e.g. Hemabate) either
- high risk of PPH and placenta accreta/increta/percreta
- optimize preop Hb levels
- meticulous surgical technique
- consider preoperative internal iliac balloons that can be inflated if massive hemorrhage occurs
- potential for gravid hysterectomy
- discuss all contingency plans for massive hemorrhage including aortic cross-clamp
- complication is she is a Jehovah’s WItness
- discuss which products she is willing to accept
- discuss if cell salvage is acceptable
- once again, meticulous surgical technique (not a “learning case”)
- consider tranexamic acid
- discuss plan if baby needs transfusion – have time to obtain court order ahead of emergency and bioethics counsel
- post-operative monitoring in high dependency unit
What do you think of the plan? Is there anything you would add or change?
You are waiting in line at the hospital coffee shop and see the patient waiting in line ahead of you. After getting her coffee she suddenly grabs her belly in pain and promptly collapses on the ground.
What do you do?
You rush to the patient’s side and see that they are breathing and have a pulse, albeit fast and thready. You call for a code blue, and with the help of the code team you put her on a stretcher and rush her to the L&D C-section suite.
The OB says there is some uterine bleeding and the FHR is slow – 80 bpm but present. She is worried about abruption and want to proceed with C/S emergently.
With some fluid resuscitation your patient actually becomes more alert and vitals are HR 100 afib, BP 95/50, SpO2 97% on 10L facemask.
Do you want to optimize her anymore for surgery? What is your anesthetic plan for this emergent C/S?
Thanks for all your responses this week! We move on to the final chapter…
You called for help and the code team arrives. She has a weak pulse but she regains consciousness with a fluid bolus and you are able to rush her up to the obstetric operating room for further resuscitation. The FHR is 80. The OB has noted some vaginal bleeding. She is currently 32 weeks gestational age.
After a short discussion with the team, it is decided to proceed with emergency c-section. You’ve placed an arterial line and two large bore IVs. You have a completed JW blood products form that states that she will accept albumin, recombinant factors and prothrombin complex concentrates, DDAVP, TXA, and cryoprecipitate. Blood bank was notified to prepare products for her.
A second anesthesiologist was called to help as well because of her hemodynamic issues as well being a very complex case. Neonatology was paged for potential resuscitation of the neonate.
Because her LMWH was not held, an epidural could not be performed. A general anesthetic was induced with very careful attention to hemodynamics and a TEE probe was inserted after intubation.
After deliver of the neonate, the obstetrician proceeds to do a hysterectomy and the patient is extubated and transferred to ICU with an estimated blood loss of 1.5 litres of blood.
After 2 hours you are called back to ICU because the patient’s heart rate is 140, and the ICU team wants you to start more analgesics for her.
What do you do?
Thank you to everyone for reading/tweeting about #gasclass this week! Hopefully there will be more “difficult” cases to come in the near future!
In the meantime, here is our Storify summary.
Remember there are no right or wrong answers! Please tag your tweets with #gasclass!
We’d like to give a big thank you to the fantastic @mjslabbert for facilitating last week’s trauma case. We had a lot of involvement and discussion from some new and old followers.
This week, we will be featuring another guest facilitator. Dr. Clyde Matava is a pediatric anesthesiologist from Sick Kids Hospital in Toronto, Canada, with special interests in medical e-learning, innovation, and technology in practice and learning. He also runs the Pediatric Anesthesia twitter account.
It is Saturday late morning and you are on call. You receive a page from the neuroradiologist who is requesting an emergency (priority 1) MRI for a 7 month old (6.5kg). The child was previously healthy, had good milestones and presented to ER this morning. The parents report that the child stopped moving her left hand yesterday. While concerned, the parents were not particular anxious about this. However, this morning, a few hours after breakfast, the patient had a left sided seizure and what appeared to be weakness of the whole left side. Neurology and neuroradiology are requesting a stat MRI. The patient is awake and responsive with some flaccidity of the left side. There have been no further seizures.
What are the differential diagnoses?
What other information do you require?
What are your anesthetic considerations? What would you do differently for an elective versus emergency MRI for a child?
Thank you for your comments on twitter. So the case started yesterday with a child who had normal milestones but presented with a brief history of a single seizure and what appears to be left sided weakness. The patient requires an MRI.
What are the differential diagnoses?
As @Neil_brain1 alludes to, the differentials list is pretty wide. Unfortunately, this is common in infants particularly with a sudden onset on clinical symptoms devoid of a prodromal phase.
The common issues in pediatric neurology are
Intracranial tumours (supratentorial and subtentorial)
The primary issues for the anesthesiologist are
the presence or risk for raised ICP
progression of pathology such as bleeding, stroke etc
What other information do you require?
Milestones, family history and other symptoms are important, family history of MH.
With a good NPO status, often enough a gas induction, followed by nasal prongs and a propofol infusion will suffice for a routine MRI brain scan. These scans are typically 30-40 mins long.
However this case is an emergency. You are concerned about the possibility of a bleed or a tumour and so ask that neurosurgery be consulted. Neurosurgery confirms that a tumour is possible and they need to take the patient to the OR if this is a tumour. Furthermore, neurosurgery does not rule out the possibility of the patient needing to go to interventional suite if warranted.
A systemic review shows a previously health child with no known allergies, all immunizations are up to date.
The child last are some cereal 4 hours ago.
You examine the patient and note the following:
GCS 12/15 but patient is responsive
Weakness of the left side
HR – 110
BP – 100/50
RR – 30
No IV access
You prepare for the anesthetic.
What is your plan? What are your local practices?
Going forward we will move quickly through the rest of the case.
You decide to do an IV start and modified rapid sequence IV induction in view of food intake 4 hours ago. You have considered also considered starting an IV under oxygen and nitrous oxide or even inhalation induction if the IV start is difficult. A distressed and screaming child during multiple IV attempts may worsen the underlying pathology particularly if it is a bleed.
You get the IV on the first go and proceed to intubate the patient. The MRI proceeds uneventfully, however the scan reveals a right sided grapefruit sized supratentorial tumour arising from the ventricle with midline shift and flattening of the gyrii. The neurosurgeon believe this to be a choroid plexus tumour and needs to removed immediately. They will need the patient positioned supine with head turned laterally. As a passing comment, the neurosurgeon, remarks ‘these really pour’.
You move the patient to the OR. Currently your patient is stable, with one 24 gauge IV line and a size 4.0 microcuffed ETT.
What are your concerns regarding the patient and procedure?
What monitoring will you need?
What potential issues might you face and how are you planning on mitigating them?
Welcome back after the weekend.
At the end of last week, we were faced with a conundrum of consenting proportions. Consenting around MRIs is a key element of providing pediatric anesthesia. Discussions at recent pediatric anesthesia meetings do suggest that consent for GA is obtained for MRI, even-more-so when patients are critical with a worsening condition. True informed consent has a few key components and always involves a patient. In pediatrics, the concepts of parental permission and patient assent (age appropriate) come in to play. A few great articles on this can be found here.
Going back to the case.
Following a lengthy discussion with the ICU, Surgical and anesthesia, Chaplaincy department, the parents provide consent for surgery. The surgeons estimate 4 hours of surgical time.
The patient is lined up with
- 2x 20ga IVs (saph & arm),
- art line
- urinary catheter
- blood/fluid warmer
- underbody body warmer
- maintained on sevo/remi, oxygen and air.
- Frequent Bedside blood sampling for Hb, lytes and gases.
- Low EtCO2
Within an hour of surgery, it is clear there is continuos bleeding from the tumour. The suction has been running continuously and you have been working hard to keep up. The patient has already lost ⅔ of their estimated blood volume. You continue your work for 4 hours and the final tally estimates blood loss at two blood volumes.
How did you manage the patient?
What was your strategy for blood products in pediatrics with large ongoing blood loss?
What is your local institutional practice for massive transfusion cases?
What complications have you seen?
Remember there are no right or wrong answers. Please tag your replies with #gasclass!
Back in resus with our polytauma patient that has deteriorated. You are a bit baffled by it all. A sudden unexpected dramatic change in his condition has lead you to believe what you are seeing is a patient that is having a stroke right there in front of you.
A stroke? Really? Scenarios of “what came first, was it the chicken or the egg” runs trough your mind: Can it be that the patient had a transient ischaemic attack and then crashed? Is it coincidental? Are these two separate pathologies? Or a drug effect , or a bleed?
Regardless of the cause for this, in true anaesthetist style you decide it is more important to support than diagnose and decide to give that patient an anaesthetic, secure the airway, control ventilation and then have a team hunt for the diagnosis to explain how a quite boring Saturday afternoon has unraveled into this enigma!
- How would you anaesthetise this person? What drugs would you use?
The question remain: What is going on? The answer doesn’t seem that clear to your slightly overwhelmed and tired brain at the moment. There is no external signs of a head injury in this patient and the plain c-spine films didn’t show any cervical spine fractures. Never ever have you seen this before, so surely it must be rare or not even a thing. Then one of the nurses asks a question that sort of just hangs in the air: “Surely a whiplash injury can’t give you this neurology? Or a blow to the neck maybe?
Slowly you baffled mind refocuses on the neck area. “Can it?” You wander. “Can a rapid deceleration and rotation of the neck put enough stress on the vessels in the neck to cause this? And add to this a seatbelt..”
With your patient now anaesthetised, the team decide further imaging is required.
You decide it might be some sort of vascular neck injury affecting cerebral perfusion.
- What imaging will confirm your suspicions?
- How do traumatic carotid dissections classically present?
- What is the treatment for traumatic carotid dissections?
- What are important consideration in polytrauma patients with traumatic carotid dissections?
Put your thinking caps on. Google or bing or consult your textbooks. Try and share helpful links if you find any and remember to use the hashtag #gasclass in your tweets so that everyone can follow it.
Case conclusion tomorrow ( or in my case, later today, since the sun is just rising on my theatre night shift).
Be part of the conversation.
Welcome to a new week of Gasclass! This week we’ll talk about a short series of pediatric anesthesia cases.
Case 1: You are on-call and paged by ENT because they want to book a 2 yo child for extraction of foreign body.
How will you manage this situation?
As mentioned on twitter, there are two options for induction: inhalational or IV.
You induce the child with an inhalational induction because they do not have an IV. After placing an IV asleep, you continue to deepen the anesthetic under spontaneous ventilation and test the depth with laryngoscopy. While going in with the laryngoscope and about to spray the cords, you notice a piece of white-yellow food (possibly nut?) just at the laryngeal inlet below the epiglottis.
What would you like to do at this point?
Case 2: General surgery has booked a 2 mo boy for pyloromyotomy. They have asked for a preop consult because of a diagnosis of sickle cell disease.
What are your considerations for this surgery? What are your goals for preoptimization?
Thanks for all the responses! Common themes seemed to be:
– this is non urgent surgery and patient’s fluid status and electrolytes should be preoptimized
– concerns for sickle cell disease: warm, hydrated, good analgesia (? Regional techniques), crossmatch may be difficult if previous transfusions and alloantibodies
– consultation with hematology for optimization preop (physiologic anemia of infancy, preop transfusion)
– might benefit from postop ICU monitoring?
Case 3: you are doing a tonsils and adenoids list.
What are your criteria for suitability for outpatient T&A vs inpatient admission? How do you assess for pediatric OSA?
The next child, a 4yo boy, has been snoring so loudly his parents say “the walls shake” as well as having overall daytime somnolence, decrease in activities and witnessed “breath holding” spells when asleep. He has not had any investigations (sleep study, overnight oximetry) or treatments. He is average weight but parents feel he would not be cooperative with a preinduction IV. He has grade IV kissing tonsils on exam, with audible noisey breathing at rest.
What investigations (if any) would you like? What is your anesthetic plan?
Remember to tag your tweets with #gasclass! There are no right or wrong answers.
We’re terribly sorry that there was such a long hiatus since the last term finished. Let’s just say life got in the way- but we’re coming back!
Stay tuned to this space next week and also on Twitter – follow the @gasclass account and search using #gasclass tag to see other people’s replies.
As always, there are no right or wrong answers. It is meant to promote discussion and awareness of basic and advanced topics in anesthesia and critical care. Please include #gasclass in your tweets when you reply!
Good Morning and welcome to this weeks #gasclass.
You are the on call anaesthetist covering the critical care unit at a small District General Hospital. You have been asked to attend the Emergency Department where a 42 year old man has been brought in by ambulance having been found unconscious at home.
As you walk to the Emergency Department What are your initial thoughts?
You arrive in the Emergency Department and find that the man remains unconscious. The paramedics tell you that he was found at home surrounded by various tablets and bottles, none of which have any labels on them. On examination he is unresponsive to pain, hypotonic and hyporeflexic. His pupils are dilated and react only slowly to light.
What are your thoughts now? What are your next steps?
Whilst assessing the patient his breathing becomes laboured, following which he suffered recurrent grand mal convulsions. His biochemistry reveals: Na 163 K 4.8 Ur 5.7 Cr 290 ABG pH 7.06 pCO2 1.52 pO2 19.6 HCO3 3
What are your thoughts now? What is your plan?
You have decided to intubate and then take to CT on the way to ICU. How are you going to do this?
CT is unremarkable, and the man is transferred to the ICU. Over the course of the next 12 hours he becomes cardiovascularly unstable, develops pulmonary oedema and is anuric.
Repeat bloods reveal Na 165 K 5.2 Ur 7.9 Cr 350 Ca 1.4 Anion Gap 60
Whats are your thoughts? What do you do now?
Some interesting suggestions last night, paracetamol is undetectable. You locate his old notes and discover that he has previously been admitted with overdose of antifreeze. Could this be the case now?
If we assume that the man has taken a significant volume of antifreeze how do we treat him?
There are no trick questions in #Gasclass. Everyone’s contribution is welcome. Please do not forget to add the ‘hashtag’ #gasclass to every Tweet so that it is included in the conversation. To help give new contributors an opportunity to join in we would advise that you should only add one idea per tweet and not contribute until another Tweeter has joined in.