small bowel obstruction, aplastic anemia - anesthetic management
TRANSCRIPT
Morning ReportAalap Shah, MD
Elizabeth Eastburn, DO11.17.2015
# Procedures
I
II
III72
2ASA
Cases by ASA Classification
# Patients
GS 5
Ortho3
Optho1
Onc1
GI1
Cases by Surgical Service
0
1
2
3
4
5
6
GS Ortho Optho GI Onc
Cases by Surgical Service and ASA
I II IIIASA
Cases by Surgical Service and ASA
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
0-1 mon 1-12 mon 1-2 year 3-11 year 12-17 year 18+ year
Cases by Patient Age
Weekend Cases 10/16-10/19
ASA 1 ASA 2 ASA 3
10 y/o M with supracondylar humerus fx s/p CRPP, long-arm cast
14 y/o F with B-cell ALL s/p PICC placement and LP for IT chemo
2 y/o F with aplastic anemia, CMV enteritis vs GVHD s/p EGD/flex sig
14 y/o M with L. 2nd digit fx s/p CRPP
15 y/o M with SBO s/p PICC placement
9 y/o M with hepatitis –induced aplastic anemia, candidiasis s/p PICC placement
18mo F with R. 4th finger near-amp s/p soft-tissue release
9yo F with appendicitis s/p lap appy
14yo M with R. testicular rupture s/p repair and scrotal exploration
18mo M with appendicitis (ruptured) s/p appendectomy
5yo F with L. eyelid preseptalcellulitis s/p EUA
15 y/o M with SBO
HPI
• 15 y/o M with diffuse abdominal pain x 6 months and SBO. Transferred from OSH.
• 20 lb weight loss x 6 months
• Plan for PICC and PN, with plan for lap-assisted abdominal exploration later in week
PMHx: - Intermittent, mid-abdomen- No previous [abdominal] surgery- +Post-prandial pain - No rectal bleeding, perianal sx or extra-GI s/sx
Labs:CBC: WBC 5.8, Hct 35.9, Plt 265, PBS wnlBMP: Na 130, K 4.2, Cl 91, Glu 72, BUN 14, Cr 0.6LFTs: Alb 3.5, Pre-albumin
Amylase/lipase wnlOSH FOBT +
15 y/o M with SBO
• Urgency of Abdominal Exploration?
• DDx?
• Fluid repletion / electrolyte goals
• Are you worried about the FOBT +?
• Would you place an NG prior to anesthesia?
• What is refeeding syndrome?
Anesthetic Plan?
• Pre-med: 2mg IV midazolam
• Airway: Natural airway, NC
• Induction: Propofol 120mg
• Analgesia: Fentanyl 50 mcg
Post-Anesthesia
• Started PN
• To OR for lap-assisted SBR --? 4cm terminal ileum w/ stricture removed
– C/f IBD given transmural inflammation and fissuring, previous perforation site
• Transitioned to PO diet on POD5, discharge with f/u colonoscopy
SBO: Management Pearls
• Non-operative management successful in 65-81% of cases w/o peritonitis
– Without the presence of free air, SBO is a medical diagnosis
• Electrolyte abnormalities:
– hypo Na, K, H/Cl volume contraction alkalosis
– Refeeding sx phosphate, glucose, thiamine depletion in response to carbs K, Mg depletion Cardiac arrhythmias, respiratory muscle strength during anesthesia emergence, etc.,
• DDx is vast, but why do we care?
– Infection SIRS low SVR state, preload goals
– Hernia r/o strangulated components
– Chronic + wt loss r/o oncogenesis
– Adhesion/previous surg Bleeding, longer duration, opioid-induced ileus
– IBD
• NG provides symptomatic relief, decreases need for intraoperative decompression
– Must weigh against current n/v and patient discomfort with NG placement
– No outcome differences between NG and NJ
Weekend Cases 10/16-10/19ASA 1 ASA 2 ASA 3
10 y/o M with supracondylar humerus fx s/p CRPP, long-arm cast
14 y/o F with B-cell ALL s/p PICC placement and LP for IT chemo
2 y/o F with aplastic anemia, CMV enteritis vs GVHD s/p EGD/flex sig
14 y/o M with L. 2nd digit fx s/p CRPP
15 y/o M with SBO s/p PICC placement
9 y/o M with hepatitis –induced aplastic anemia, candidiasis s/p PICC placement
18mo F with R. 4th finger near-amp s/p soft-tissue release
9yo F with appendicitis s/p lap appy
14yo M with R. testicular rupture s/p repair and scrotal exploration
18mo M with appendicitis (ruptured) s/p appendectomy
5yo F with L. eyelid preseptalcellulitis s/p EUA
2 y/o F CMV enteritis w/ GIB
HPI
• 2 y/o F, now 2 mo s/p BMT for aplastic anemia, admitted 10/8 for fevers, vomiting/diarrhea
• Presenting for colonoscopy
• Inpatient course significant for:
• CMV diagnosis (PCR)
• progressive hypoxic respiratory failure
• Endocarditis, pericardial effusion w/o tamponade
• Transaminitis NOS
• Recent C. diff
• Bloody stools, multiple PRBC and PLT Tx
2y/o F CMV enteritis w/ GIBRx:- Cyclosporine TPN- Furosemide Fat emulsion- Foscarnet- Ciprofloxacin, Voriconzole, IV Vancomycin, Meropenem- Lorazepam / Morphine (+ Morphine NCA)- KCl
Previous Anesthetics:- BMA {6/15, 8/15},
PICC {10/15}- IV induction, Gr 1 View (Mil
1 / Wis 1)- ETT replaced (4.0
3.5)*,**
- *Replaced due to inability to pass
- **no leak
- Previous post-op stridor
VS: 140/91, HR 76 NSR, SpO2 96% (FiO2 30%), RR 20, Temp 37.6
Labs:VBG: 7.41 / 43.7 / 39.0 / 27 [FiO2 30%]CBC: WBC 2.4, Hct 33.5*, Plt 45; ANC 2.29
PT 13.7, INR 1.02*=s/p pRBC (Pretx Hct 19.3)
BMP: Na 146, K 2.7, Cl 112, Glu 135, BUN 11, Cr 0.2LFTs: Alb 1.8, Pre-albumin - ECHO 10/27:
LDH 464 (nl: 110-295) Small echobright focus on BCx: NGTD, CMV + PCR RV inflow, not present 9/14
Anesthetic Plan?
• Emergent case?
• Induction paradigm?
• Monitoring?
• Intubation? Keep Intubated?
• Blood products?
Anesthetic PlanINDUCTION:• RSI induction (Propofol 25mg, Fentanyl 12.5mcg,
Succinylcholine 20mg), pre-existing PICC• Analgesia: Fentanyl 17.5 mcg• Relaxation: Rocuronium 4mg x 3MONITORING: Standard + 22g L. RAD ARTAIRWAY: - 1st attempt swollen
arytenoids, 3.5 cETT, no EtCO2/breath sounds- 2ndWis 1 Grade 2a, 3.5 cETT
LABS: 7.32/49.7/94/25.3 [FiO2 60%]
Post-Anesthesia• Remained intubated x 4 hrs
– Wheezing / decreased air entry– Thoracoabdominal competition d/t abdominal distension
• Severe GVHD– EGD w/ extensive abnormal and friable duodenum, and gastric
mucosa
• Intermittent bloody stools, maintained on complete bowel rest
• Worsening hypoxic hypercarbic respiratory failure (HFNC HFOV)
• Made DNR 11/15 severe hypoxia (ABG pO2 50s, SpO2 40s), wide-complex bradycardia– Passed away 11/15/15 13:30
Weekend Cases 10/16-10/19
ASA 1 ASA 2 ASA 3
10 y/o M with supracondylar humerus fx s/p CRPP, long-arm cast
14 y/o F with B-cell ALL s/p PICC placement and LP for IT chemo
2 y/o F with aplastic anemia, CMV enteritis vs GVHD s/p EGD/flex sig
14 y/o M with L. 2nd digit fx s/p CRPP
15 y/o M with SBO s/p PICC placement
9 y/o M with hepatitis –induced aplastic anemia, candidiasis s/p PICC placement
18mo F with R. 4th finger near-amp s/p soft-tissue release
9yo F with appendicitis s/p lap appy
14yo M with R. testicular rupture s/p repair and scrotal exploration
18mo M with appendicitis (ruptured) s/p appendectomy
5yo F with L. eyelid preseptalcellulitis s/p EUA
HPI
• 9 y/o M from Kuwait with hepatitis-induced aplastic anemia and disseminated candidiasis
• Presenting for PICC line replacement
• Previous DL PICC (9/18) with cracked lumen
9 y/o M w/ hepatitis-induced aplastic anemia
• Inpatient course significant for :
• Anemia/thrombocytopenia
• s/p multiple tx (9u aPLT, 3u pRBC)
• Borderline PO intake (Hepatitis, ileus)
• H/o multifocal PNA (9/13), resolved
• R. thigh abscess, s/p IR drainage
• Hepatitis workup: non-typable; concern for Fe overload
9 y/o M w/ hepatitis-induced aplastic anemiaRx:
– MeropenemLevofloxacin, Voriconazole, Amphotericin, Bactrim ppx
– Omeprazole, bowel regimen - PRN Tylenol
– KCl replacement
– Ursodiol
VS: 98/57, HR 105 NSR, SpO2 99 on RA, RR 26, Temp 37.6 (max 38.3)
Labs:
CBC: WBC 0.13, Hgb/Hct 5.0/17.3, Plt 13 [10/29]; ANC 0.02, ALC 0.10
[10/31 Hct artificially high]
BMP: 135, K 3.6, Cl 99, HCO2 27, Glu 101, BUN 10, Cr 0.3
CRP: 14.1, LDH: 70
LFTs: AST 26, ALT 66, Albumin 2.9, Bilirubin wnl
BCx/KOH prep: +Candida tropicans
ECHO: Trivial pericardial effusion
Previous Anesthetics:- R. thigh abscess aspiration (10/22)
- Nat airway (NC), Propofol/Ketamine
- PICC (9/15)
- IV induction, Mac 2 Gr 1 View, 5.5 cETT, midazolam, propofol, morphine
Anesthetic Plan?
• Airway: LMA Unique 2.5
• Induction: Propofol 80mg
– Pre-existing PICC NOT used
– Pre-existing PIV 22g
• Analgesia: Fentanyl 15 mcg
• Products: Platelet Tx (121 cc)
Aplastic Anemia: Management Pearls• Misnomer - Primary failure or immunologically mediated
suppression of multipotent myeloid stem cells– Anemia + thrombocytopenia + neutropenia
• Etiologies: Chemicals, Drugs, infections
• DDx– Fanconi’s Anemia - PNH / c-Mpll– Dyskeratosis Congenita - Shwachman Diamond syndrome
• Electrolyte / Nutritional abnormalities (due to medications)– Hypo Na: SIADH, amphotericin-induced renal tubular
dysfunction– Hypo K: Amphotericin, furosemide (post-transfusion diuresis)– hypo Na, K, H/Cl volume contraction alkalosis
Aplastic Anemia: Management Pearls
• Antibiotic and other badness– Voriconazole visual disturbances (30%), transaminitis, QT
prolongation– Amphotericin – fevers (NLMS-like), renal/hepatic toxicity
• Infection precautions– Sterile technique with IV placement, Airway management (ETT or
LMA)– Apheresis platelets (single donor), leukocyte-reduced/irradiated pRBCs
• Transfusion thresholds / precautions– Institutional: Hgb < 6, Plt < 50; reassess in brisk bleeding scenarios– Non-infectious transfusion complications (TACO/TRALI, Fe overload,
DHTR)
Thank You!
• Elizabeth Eastburn, DO
• Thomas Mancuso, MD [Course Director]
• Carlos Munoz-San Julian, MD; Izabela Leahy, RN BSN MS [Course Planners]
• Jina Sinskey, MD [Slide Template]