The most challenging anesthesia cases?

  1. What do you consider the most challenging anesthesia cases and why? (For example, CV, Neuro, Trauma, etc...) Exclude complications if you would.

    Donn C.
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  2. 12 Comments

  3. by   athomas91
    LOL -- all of them!!!
  4. by   WntrMute2
    Awake crainies, especially the steriotactic ones.
  5. by   Tenesma
    here is one i did this past week:

    80 year old jehovah's witness, on&off schizophrenia, class IV airway (hx of being can't mask/can't intubate), morbidly obese (5'2" 340lbs), difficult IV stick, combative, hx of ischemic cardiomyopathy w/ EF=10 and severe MR, LVH AND critical AS (AVA=0.7 but peak=105 mean=65), uncontrolled diabetic (on 100 Units NPH and still eating sweets) for an urgent thoracic epidural hematoma (she fell that AM), severe COPD w/ an FEV1=0.8!!!, hx of tracheal stenosis (due to previous prolonged tracheostomy in the 80s - unfortunately that was closed in the 80s), recently started on HD for recently diagnosed ESRD (last HD was 2 days ago) and she had managed to rip out her recently placed right IJ "tunneled" catheter, with a creatinine of 6....

    issues: combative, awake intubation, needs an IV, critical AS and extremely poor cardiac function, and difficult volume management....

    that was a long day....
  6. by   Passin' Gas
    Wntrmute: Out of curiosity, what anesthesia technique are you using for the awake craniotomies? What anesthetic agents? We do some craniotomies at my facility but they're usually tumor excisions.

    PG
  7. by   Robinette
    Okay, you win. This is the nightmare patient of all time - that I've ever heard about!
  8. by   WntrMute2
    Quote from Passin' Gas
    Wntrmute: Out of curiosity, what anesthesia technique are you using for the awake craniotomies? What anesthetic agents? We do some craniotomies at my facility but they're usually tumor excisions.

    PG
    Well since they are locked in that frame, airway control is a priority, you cannot afford to have the patient lose their airway. You can't do a jaw lift, and to intubate meanes removing the frame place in CT scan. Supposedly a LMA can be placed but I never had to go that far. I learned to do them with mainlly midazolam supplimented with careful titration of propofol during local injection. Remifentanil would be good but it was unavailable to us. Benadryl for a backround level of sedation was also good.
  9. by   kdst
    Quote from Tenesma
    here is one i did this past week:

    80 year old jehovah's witness, on&off schizophrenia, class IV airway (hx of being can't mask/can't intubate), morbidly obese (5'2" 340lbs), difficult IV stick, combative, hx of ischemic cardiomyopathy w/ EF=10 and severe MR, LVH AND critical AS (AVA=0.7 but peak=105 mean=65), uncontrolled diabetic (on 100 Units NPH and still eating sweets) for an urgent thoracic epidural hematoma (she fell that AM), severe COPD w/ an FEV1=0.8!!!, hx of tracheal stenosis (due to previous prolonged tracheostomy in the 80s - unfortunately that was closed in the 80s), recently started on HD for recently diagnosed ESRD (last HD was 2 days ago) and she had managed to rip out her recently placed right IJ "tunneled" catheter, with a creatinine of 6....

    issues: combative, awake intubation, needs an IV, critical AS and extremely poor cardiac function, and difficult volume management....

    that was a long day....
    that is a nightmare! how'd you do it?:imbar
  10. by   pasgasser
    Tenesma sounds like tough case.

    Regarding awake crani's try using dexmeditomidine. It provides exceptional sedation while not decreasing respiratory drive and increasing PaCO2 (important for awake tumor removal). I usually give small boluses of propofol for pinning and the bone flap and dex. is good sedation for the remainder of the case. The other benefit is that eventhough the pt. is sedated the drug can be titrated so that a neuro exam is always available (the whole purpose of an awake crani.)
  11. by   Tenesma
    i love dexmedetomidine... however it is tough to get pharmacy approval for it - they only let us prescribe it in the ICU and then you have to promise your first born...

    but if you can't use dex, you can always put on a clonidine patch a day or two before the surgery and then give them 0.2mg clonidine PO in the AM of the case.... nice background sedation, just not as powerful as dexmedetomidine...
  12. by   TraumaNurse
    A question here from a not-yet-anesthesia-provider, under what conditions would you be doing an awake crani? Why awake vs general? Thanks.
  13. by   WntrMute2
    Quote from TraumaNurse
    A question here from a not-yet-anesthesia-provider, under what conditions would you be doing an awake crani? Why awake vs general? Thanks.

    If the tumor is located in an area that is close to an area such as the speech center then the surgeon doesn't want to go mucking around blindly. Having an awake patient allows for assessment during the case. Also, if there is a seizure foci that has prodromal symptoms, the surgeon can use stimulation to elicit the symptom and zero in on the foci. Most of the time, the stereotactic ones I've done were for tumor biopsies and I'm not sure if the reasons are the same. i did one for a C-J diagnosis once as a student and that was really creepy.
  14. by   duckboy20
    Wow! I am loving hearing about these cases! I am excited about starting clinical in august!!

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