Panniculectomy

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).

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.

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.

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.

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

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

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

Thanks for the update, hope post op goes as smooth as the surgery.

Need to talk to RNs re continous epidural analgesia. I am also in a small place, less than 50 beds total, and at first we were apprehensive about them but have grown appreciate them. If my memory serves me right continous and bolus epidurals are used for chronic pain patients in the home. Its really just a combination of knowledge and comfort level.

a few thoughts:

i agree with the caution regarding the airway... however I also agree with both epidural and getting pre-op echocardiogram. However since the patient is in his 30s i doubt he has any significant shunting from an endocardial cushion defect, but an echo would have been nice none the less. Due to the body morphology i also agree with the a-line, both because of the possible difficulty in recording a blood pressure, but also due to the requirement for multiple labs/following glucose... I wouldn't be too keen in getting central access on this patient, primarily due to the higher rates of complications in obtaining central access in morbidly obese patients, and because of the higher risk of infection in somebody who already has risk factors (unless of course the patient is a horrible stick and therefore you won't have any IV access without central access, then by all means!!)

what i didn't understand was the methodology of induction/intubation... if the plan calls for a sedated awake fiberoptic intubation why did you give propofol/succ before putting the tube through the cords? i would say that was very lucky, i have been in similar situations many times and quite a few times that has backfired.... You see the cords, you push your drugs, and then due to the excessive airway tissue you lose your view and the patient no longer has his own airway protected!!!

So a favorite technique of mine for when i am in the OR (this doesn't work as well for coding patients on the floors - there i just use versed and benzocaine spray) is to run a remifentanyl drip starting very slowly until their respirations go down to 3-4/minute, visualize the cords, spray the cords with lidocaine, then place the tube.... now of course there is the chance that the patient will buck, but at least the airway is secured without a doubt....

patients with down's syndrome typically have large tounges, small mandibles, and an increase in subglottic stenosis. other than just safety of cspine in someone obese with a probable short neck i'm at a loss. please follow up.

thanks

d