The most challenging anesthesia cases?

athomas91 · Apr 17, 2004

LOL -- all of them!!!

WntrMute2 · Apr 17, 2004

Awake crainies, especially the steriotactic ones.

Tenesma · Apr 17, 2004

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....

Passin' Gas · Apr 17, 2004

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

Robinette · Apr 17, 2004

Okay, you win. This is the nightmare patient of all time - that I've ever heard about!

WntrMute2 · Apr 17, 2004

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.

kdst · Apr 17, 2004

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

pasgasser · Apr 18, 2004

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.)

Tenesma · Apr 18, 2004

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...

TraumaNurse · Apr 18, 2004

A question here from a not-yet-anesthesia-provider, under what conditions would you be doing an awake crani? Why awake vs general? Thanks.

WntrMute2 · Apr 18, 2004

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.