September FY22

[kristenhorsman]

The September journal club article is presented by Dahlia Rouchon. She chose an article entitled "Acute Respiratory Distress Syndrome Management in COVID–19 Patients". Being in the middle of a pandemic with historic proportions and definitive implications for anesthesia management, there are many things to consider. The article is a review on the clinical impact of COVID on patients and its management in general.

You will find the link to the article here.

Please answer the following two questions:

If you had a patient BMI 50 for lower extremity surgery (cannot do local) refusing regional anesthesia, on home O2, dyspneic with exertion, and CT shows interstitial lung disease with fibrosis:



1. What preop tests would you like to see? What other considerations would you have? 
2. What would be your anesthetic? What ventilation strategies would you use? Are there any special medications you'd have available?

[LarSharVeA Bailey]

This is an excellent article. I particularly appreciated the explanation of ards vs covid-19 ards, emphasizing that there appears to be no difference in management while there are overt differences in pathophysiology: "hypercoagulability, including microvascular thrombosis within the lung vasculature, leading to ventilation-perfusion mismatch and right ventricular stress." Some academic centers were allowing permissive hypoxia with well documented outcomes at the start of the pandemic, however, the article mentions discontinuation of a study due to mesenteric ischemia and increased 28-day mortality. There's an obvious fine balance between management of the effects of hyperoxgenation and that of hypoxia.

With the case presented above, there are not any particular tests that will shift the clinical picture. PFTs will confirm restrictive lung disease with a decrease in all capacities, CT in alignment and findings are superior to a chest xray. With all the focus on the lungs, let's not neglect circulation, so perhaps an echocardiogram prior to surgery. If said patient can not receive local because of an infection, it would be understandable. However, considering the imminent and long term morbidity and mortality of this patient, unsubstantiated refusal warrants an education from the team at large. Instrumentation of the airway may result in prolonged intubation and the cascade of adverse effects associated (ventilator associated pneumonia, etc) pose a threat to the already grim clinical status. So, I recommend regional anesthesia, with minimal precedex at 0.3mcg - 0.5mcg/kg/hr max, no bolus and ketamine 0.3mg/kg/hr, no versed, no fentanyl, no propofol.

[Matthew Soladay]

1. The article noted the increased incidence of pulmonary microvascular thrombi as being a cause of right heart strain. Right heart strain is common in chronic hypoxia and lung disease. This reminds me of the talk we had by Dr Abernathy regarding this same concern. Preoperative echocardiogram would be essential for this patients care. A pharmacologic stress test would also be useful to assess the hearts ability to handle increased Mvo2.
2. Awake arterial line using ultrasound, judicious local anesthetic. Ramp position, pre-o2, RSI using BP-friendly induction agent of choice + succinylcholine, CMAC DBLADE (or equivalent). I would have 'baby epi' of 10mcg/ml prepared in case instability as we don't want right heart to fail. Desflurane. Ketamine may help with post op pain since no local can be used while reducing total amount of opioids. Predicted body weight with 6ml/kg tidal volumes very reasonable, PEEP titrated to effect.

[aileenm4]

considerations of preop evaluations and or work up may include the use of EIT or electrical impedance tomography and utilization intraop of EIT as well, reaching out to our cardiac and pulm HTN team experts to see if optimization is needed with medications, we also have a lung rescue team that helps to manage ventilation during intubations/ventilations of complex patients
There needs to be a team discussion between, patient, anesthesia and surgery about the pro and con for patient care/outcome before the patient " refuses " regional. If not an emergency then discussions should happen because of the very high risk of morbidity and mortality for this patient.
If GETA absolutely needed then I agree with others about multimodal , awake aline, emergency meds, but also utilizing the high peep needed and ventilation strategies.

[Kels]

1.) I agree with all of the answers my colleagues have provided . I also would like to see an echo/ stress test, chest imaging, labs etc. like most of my colleagues have said. I do think a discussion with the patient is the most important in this case about the pros and cons of GA vs regional . Why is the patient refusing regional in the first place? In addition to a team discussion I would probably get the CIP involved and make sure an ICU bed is ready for the patient .
2.) If I must provide GA then I agree with my colleagues about a multimodal approach anesthetic. For ventilation I would probably use lower tidal volumes and higher peep to start . I too would have baby epi drawn up and ready .

[Anne McNulty]

I agree with most of the above discussion. Regarding patient refusal of regional , I would find a clinician that can develop a harmonious relationship with the patient. The patient needs education and trust. The preop studies are all in my agreement. What I would do differently would be awake fiberoptic intubation with Dexmedetomidine as well as awake aline. Central line or Picc line is a definite need. I would like results of echo to best determine what meds to use for GA. I have never seen EIT in use but this pt would be a candidate. I would use ketamine , dexmedetomidine and low dose desflurane. He is on the schedule for Tues!!

[emedina1]

I agree with my colleagues about all the pre-op evaluation. i also agree with the idea op establishing a very good rapport with then patient to gain the trust.

[nanci]

1. What preop tests would you like to see? What other considerations would you have?
Cardiac function testing to assist with evaluation for this patient as he also has dyspnea and history/current use of home oxygen. Recent chest xray and labs. Also consider the need for continued oxygen therapy postop and possible ICU admission if needed to remain intubated and bed availability. Consent for arterial line and consider possibility of difficult airway as well.

2. What would be your anesthetic? What ventilation strategies would you use? Are there any special medications you'd have available?
Agree with above recommendations of anesthetic and a head up position for induction to help optimize and maintain Functional residual capacity (FRC). Propofol (help decrease airway resistance and rapid induction), ketamine (for the bronchodilator properties and to help increase sympathetic tone), opioids (short acting Remifentanil, Precedex or volatile agent (desflurane or sevoflurane) also good for maintenance. Low tidal volumes (6 ml/kg) I:E ratio of 1;1 to 2:1 to minimize risk of high intrathoracic pressures. Can make it more complex but keeping it simple may work better. Titrate to effect.

[Catherine Lawry]

Please answer the following two questions:





If you had a patient BMI 50 for lower extremity surgery (cannot do local) refusing regional anesthesia, on home O2, dyspneic with exertion, and CT shows interstitial lung disease with fibrosis:











1. What preop tests would you like to see? What other considerations would you have?



I would like to see labs such as coags, cbc, comprehensive metabolic panel, covid test. PFT's, EKG, and Echo would be helpful to have in managing this case. It is concerning that patient is on O2, has DOE, and interstitial lung disease. I would want to make sure that patient is medically optimized prior to surgery or case may be cancelled unless this is an emergent case. For example, if pt has low EF, I would have pt admitted and monitored prior to surgery. 

2. What would be your anesthetic? What ventilation strategies would you use? Are there any special medications you'd have available?

GA with ETT due to BMI of 50. I would tell the patient that they were high risk for staying intubated after the procedure. I would implement a lung protective ventilation strategy with tidal volumes no greater than 6 ml/kg IBW. I would use optimal PEEP for the patient and permissive hypercapnia. I would use a multimodal approach for analgesia including ketamine and precedex to decrease the amount of narcotics used in the case.