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| |  Panniculectomy
Looking for some input from practicing anesthesia providers.
We have a panniculectomy scheduled for this week for non-cosmetic indications. Pt is mid-30's, with trisomy 21 and NIDDM. Pt has fairly high level mental function, and is able to understand the procedure, instructions, and implications, and can sign own consents for surgery.
Mallampati II airway, pt is scheduled for EKG, CXR, CBC, ABG, coags, and comprehensive metabolic profile, all of which will be reviewed prior to surgery. Anesthetic plan is for sedated awake intubation, followed by general anesthesia. Triple lumen central line will be placed with CVP monitored. We are also going to place an arterial line to monitor BP and intra op and post op ABG's. We are crossmatching for four units of blood, with two to be in the room at induction.
Post operative plan includes at least one night in ICU. Pain management will be with PCA MS. Pt is aware that they must be out of bed within 2-4 hours post op. Surgeon is planning for post op heparin therapy as well.
We are planning for both CRNA's to be in the room on induction, and will probably have one manage anesthetic and one manage fluids during the case (it's nice to be at a small hospital where we can do this). We have discussed the anesthetic plan with the surgeon, and told him that we will have a fairly low threshhold to cancel the case. If we are unable to get a tube in or if there are other complications at induction, we are planning to cancel.
So, what am I not thinking of?
Kevin McHugh
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| | Advertisement Sponsored Links | | | | No. 1 | 
Jan 10, 2004, 06:24 AM
Updated
Jan 10, 2004 at 06:29 AM by suzanne4
I am not a CRNA but an OR nurse. I also have over 20 years of Critical Care experience from open heart to neuro, peds, and NICU. All of the panniculectomies that I have been involved with have been more similar to "large" tummy tucks adn everyone of the patients did great. Many were having the procedure done for cosmetic purposes after we did their stomach stapling months before and all did great. We never used any central lines on any of them. Only did awake intubation because of "neck" problems. I know with your type of patient the awake intubation is preferred, but why are you putting in a central line and an a-line? How long is your case boarded for?
Something sounds peculiar to me................................
A panniculectomy at least to what I know and have done, is removing a large piece of redundant skin and tissue due to a loss of alot of weight. Do you have another reason that they are doing this procedure? Does your hospital do these procedures often or is it ususual in your hospital? Just thinking, we never had these patients typed and crossed, always just a type and screen................what other procedures has this patient had, that is now requiring this? Just trying to help you out with a second thinking cap on, hope that you don't mind. I have worked in hospitals that had only 40 beds on a Indian reservation to hospitals with over 1000 beds so have had a varied experience.
| | No. 2 |
Jan 10, 2004, 01:01 PM
When we do them we usually do not place central or arterial lines unless there is a specific concern for that particular patient. Biggest issues have been infection, wound healing, pulmonary status, and of course pain control. Most have been extubated post-op.
If I were doing one in a facility that does not normally perform them, with a surgeon who does not frequently perform them. I would do just what you are doing. As being prepared for any event tends to reduce the occurence. (keep the evil spirits away).
| | No. 3 |
Jan 10, 2004, 02:18 PM
While it does sound like a bit of overkill, I think you are right in approaching this paitient cautiously.
Trisomy 21 patients are known to have difficult airways, and a MP II does not indicate that you will have an easy time of it. Additionally trisomy 21 patients are known to have anatomic abnormalities of the cervical spine, and extension of the neck during laryngoscopy is to be avoided.
An awake fiber optic intubation is an excellent choice in this case in my not so experienced opinion.
Additionally, the preoperative precautions seem to be right on target, especially in light of the congenital heart problems usually associated with trisomy 21. You are indeed lucky that you have two providers, especially since, being in a rural environment you do not have the luxury of backup to call in at a moments notice.
I am very interexted to hear the followup on this case.
BTW if you do cancel, since it is a non elective case, will you be sending it to anotherr facility, or revising your technique and attempting again at a later date?
Good luck.
| | No. 4 |
Jan 10, 2004, 02:48 PM
Your approach seems right on target, the suggestion for fiber optic assist is also a good one.
Am curious about one thing though, if this is for non cosmetic reasons (other then to convince insurance company that it is needed) what are those reasons?
Agree let us know how it turns out.
| | No. 5 |
Jan 10, 2004, 06:55 PM
Updated
Jan 10, 2004 at 06:59 PM by kmchugh
The case is not being done for cosmetic reasons. The patient does not have an empty pouch of skin from which fat was lost. The panniculum is large, and the patient frequently suffers from boils and infections from pressure ulcers that form in the folds of tissue. Owing to the mental condition, the patient cannot effectively control food intake, and therefore is unable to lose weight.
The case is being undertaken because of the frequent infections. The patient's physicians are concerned with the patient developing sepsis from one of these infections. The patient is also unable to perform most ADL's at this point. They cannot wipe themselves after a bowel movement, are unable to tie their shoes without lying on the floor, and mobility has been greatly decreased. The patient suffers frequent falls owing to balance problems caused by the weight of the panniculum. So, it must come off.
We are expecting a great deal of blood loss. Because of that and the potential for congenital cardiac conditons, we are planning for the central and arterial line. I will also use the arterial line intra-op to check ABG's for ventilation.
Kevin McHugh
Edited to add: Given that the patient is also a type II diabetic, we are expecting problems with wound healing post operatively, but those are issues the surgeon will have to deal with.
| | No. 6 |
Jan 10, 2004, 07:34 PM
hey kevin just a thought here...if there are concerns about possible congenital heart problems how about an echo a day or so prior to surgery to assess EF. could give you a heads up.
just a thought
d
| | No. 7 |
Jan 10, 2004, 09:12 PM
What is the patient's weight and BMI? I would consider an epidural for post-op pain control. It may be a problem inserting one on a very large person, but I think you would have less respiratory depression than with the morphine PCA.
In my plastic surgery practice, we do those cases for cosmetic reasons and they are not as difficult as when they combine them with an abdominoplasty, which requires muscle relaxation leading to further post-op respiratory issues. Also, this patient is a set-up for a post-op pulmonary embolism, so take all precautions and look for early ambulation.
You are lucky to have another pair of educated hands to assist with this case. I like to get another CRNA in to help me with anticipated difficult intubations. It is money well spent.
Let us know how it goes.
Yoga crna
| | No. 8 |
Jan 12, 2004, 07:42 PM
Update
We did the case today, and it pretty well went off without a hitch. The patient did need the surgery, and I think will do well post-operatively.
For intubation, we had the difficult airway cart in the room, just to ward off bad mojo. Pre-operatively, we gave the patient a short breathing treatment with a nebulizer with a small amount of 4% lidocaine, followed by two sprays of cetacaine. We brought the patient into the room, hooked up the non-invasive monitors, then sedated the patient with 3 mg Versed. Once that had taken effect, we gave the patient about 40 mg propofol, which was enough to sleep the patient without interrupting spontaneous respiration. At that time, we laid the patient flat, and I used a #2 Miller to visualize the cords. Once we knew we could get a tube in, we gave the patient another 120 of propofol and 60 of sux. Intubation went smoothly, but was a little challenging. Owing to patient size (4'9", 330 lbs), there was a lot of tissue around the airway. Also, since the patient was a Down's patient, we were careful not to hyperextend the neck. (Question for students: Why didn't we want to hyperextend the neck? Sucks getting pimped online, huh?)
Placed an art line and a central line, then proceeded with the surgery. My one wish is that we could have video taped the surgery. It was a classic teaching case for ventilation. Prior to removal of the panniculus, ventilation was tough, and we had peak pressures of 48+ to achieve tidal volumes of around 350. The removed panniculus weighed about 38 pounds. Once it was removed, we were able to generate tidal volumes of about 600 while only generating peak pressures around 40. We gave two units PRBC intraoperatively, and the patient has received another two units post-op.
The patient is now in ICU and doing well. Yoga, your idea of a post op epidural had a great deal of merit, and I considered it. However, ours is a small hospital, and generally epidurals frighten nurses outside of the OR or OB. Additionally, the patient would likely have refused. So, PCA MS it is, and she isn't really using much.
Kevin McHugh
| | No. 9 |
Jan 12, 2004, 07:48 PM
Kevin, it is nice to hear that the case went well for you. Good job!
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